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490615097 | PUO | 67095171 | | 7846695 | 11/23/2006 12:00:00 a.m. | ANEMIA | Signed | DIS | Admission Date: 11/23/2006 Report Status: Signed

Discharge Date: 6/20/2006
ATTENDING: CASEBIER , WERNER REGINIA M.D.
SERVICE: LELH .
PRINCIPAL DIAGNOSIS: Anemia and GI bleed.
SECONDARY DIAGNOSES: Diabetes , mitral valve replacement , atrial
fibrillation , and chronic kidney disease.
HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old woman
with a history of diabetes , chronic kidney disease , congestive
heart failure with ejection fraction of 45% to 50% who presents
from clinic with a chief complaint of fatigue and weakness for
one week. She had had worsening right groin and hip pain , status
post a total hip replacement approximately 13 years ago which had
been worsening for two weeks , and she has also recently completed
a course of Levaquin for urinary tract infection. She presented
to Dr. Bulow office complaining of fatigue and weakness for one
week. She has had some abdominal pain in a band-like
distribution around her right side. She was found to have a
hematocrit of 21 down from 30 eight days ago and was sent to the
emergency department for transfusion and workup of her anemia.
PRE-ADMISSION MEDICATIONS: Caltrate plus D one tab orally twice a day ,
Lantus 7 units subcutaneously every afternoon , NovoLog 4 units/4 units/5 units
subcutaneously three times a day , Imdur 30 mg twice a day , amlodipine 5 mg twice a day ,
furosemide 80 mg daily , valsartan 120 mg daily , warfarin 4 mg
daily , iron sulfate 325 mg orally daily , and multivitamin daily.
PAST MEDICAL HISTORY: Chronic kidney disease , presumed due to
congestive heart failure/diuresis/renal artery disease/early
diabetic nephropathy; type 2 diabetes; previous stroke;
congestive heart failure with ejection fraction of 45% to 50%;
rheumatic valvular disease with mitral valve replacement and
tricuspid valve repair; atrial fibrillation; history of small
bowel obstruction; status post right total hip replacement
approximately 13 years ago.
FAMILY HISTORY: No family history of kidney disease or heart
disease.
SOCIAL HISTORY: She has 10 children , lives alone with home care
in Lanno Ey Me , but has moved in to live with her daughter in
Hunt Obiment Coll She denies tobacco use and drinks alcohol rarely.
ALLERGIES: Codeine and Benadryl.
ADMISSION PHYSICAL EXAMINATION: Vital signs were temperature
96.7 , heart rate 60 , blood pressure 153/74 , respirations 22 , and
SaO2 95% on room air. The patient is a frail elderly woman in no
acute distress. She has poor dentition. JVP is difficult to
assess secondary to tricuspid regurgitation. Lungs were clear to
auscultation bilaterally. Cardiovascular exam showed bradycardia
with heart rate in the 50s that was irregular , S1 plus S2 with
3/6 systolic murmur heard throughout with mechanical sounding S2.
Abdomen was mildly tender to palpation in the mid epigastrium
with no rebound or guarding. Extremities showed venous stasis
changes in her lower extremities bilaterally. Feet were cool
with diminished DP and physical therapy pulses. On neurological exam , she was
alert and oriented x3 and cranial nerves II through XII were
intact.
STUDIES: EKG showed atrial fibrillation with slow ventricular
response with heart rate of 53 , widened QRS , a Q wave in aVL , and
U waves in the lateral leads.
Chest x-ray showed improved pleural effusions and pulmonary edema , stable marked
cardiomegaly.
X-ray of the right hip showed ,
1. Status post right total hip arthroplasty with stable
periprosthetic lucency and cortical remodeling.
2. Severe left hip osteoarthritis.
3. Diffuse atherosclerosis.
EGD on 10/24/06 showed hiatal hernia , fundic polyps with
pathology showing hypoplastic and inflammatory lesions; mild
antral erosions with pathology demonstrating mild regeneration
that was nonspecific and no H. pylori; and duodenitis with
pathology showing normal mucosa but no active bleeding or signs
of recent bleeding.
Capsule endoscopy on 7/5/06 showed a healing gastric ulcer likely in the
antrum , small bowel lymphangiectasia and angioectasia in the distal small
bowel.
Colonoscopy on 9/12/06 demonstrated cecal diverticulum , approximately 3-mm
ascending sessile polyp and several small sessile polyps in the rectosigmoid.
PROCEDURE: Right basilic vein transposition on 9/12/06 by Dr.
Stacie Halechko .
HOSPITAL COURSE BY PROBLEM:
1. GI bleed: In the emergency department , the patient's vital
signs were temperature 95.4 , heart rate 62 , respirations 16 ,
blood pressure 127/66 with SaO2 98% on room air. She was found
to have black guaiac positive stool and GI was consulted. She
was started on intravenous Nexium 20 mg twice a day and was given vitamin K 10
mg subcutaneously and two units of FFP , and she was transfused
three units of packed red blood cells with Lasix 120 mg intravenous for
each bag. Of note , the patient had a colonoscopy in
Pu Fay Mont Ey , Kentucky 46365 on 8/26/05 , which showed bleeding rectal ulcers with
biopsies consistent with ischemic colitis. An EGD on 10/24/06
showed a hiatal hernia; fundic polyps ( path:
hypoplastic/inflammatory ); mild antral erosions ( path: mild
regeneration , nonspecific; no H. pylori ); duodenitis ( path:
normal mucosa ) , but no active bleeding or signs of recent
bleeding. Capsule endoscopy on 7/5/06 showed healing gastric
ulcer likely in the antrum , small bowel lymphangiectasia and
angioectasia in the distal small bowel , which were considered the
likely sources of bleeding. Colonoscopy was performed on
9/12/06 to search for angioectasias for which intervention would
be possible , but demonstrated only a cecal diverticulum and
approximately 3 mm ascending sessile polyp and several small
sessile polyps in the rectosigmoid. The patient was started on
Aranesp but had a 5-point hematocrit drop from 32 to 27 on
9/12/06 for which she required another two units of blood along
with Lasix. The patient's hematocrit remained stable at
approximately 30 to 32 and she will be restarted on
anticoagulation on Thursday , 12/10/06 , one week after her AV
fistula surgery.
2. Renal: The patient has chronic kidney disease and is being
considered for a possible hemodialysis in the future. She was
continued on her Caltrate plus D , multivitamin , and iron
supplementation and she was started on Aranesp 25 mcg weekly and
was given sevelamer 400 mg before every meal for elevated phosphate levels.
Vein mapping study was performed on 7/25/06 , and a right basilic
vein transposition was performed on 9/12/06 by Dr. Halechko . The
patient had postoperative right hand coolness , numbness , and
weakness ( always with dopplerable radial pulse ) from steal
versus neurapraxia , which was improved by the time of discharge.
She will follow up with Dr. Halechko as an outpatient. The
patient's creatinine was 3.3 on admission , improved to 2.0 by
9/12/06 , which was the day of her surgery and increased again to
3.2 on 1/10/06 .  She was given intravenous Lasix boluses as she had
evidence of volume overload with over eight-pound weight gain
during her hospitalization , and creatinine improved to 2.7 by the
day of discharge.
3. Cardiovascular:
Pump: The patient's ejection fraction is 45% to 50% and she was
given 120 mg of intravenous Lasix for each unit of packed red blood cells
she received , along with 120 mg orally daily with intravenous boluses of 180
mg as needed for volume overload as judged by an increase in her
weight. Antihypertensive medications were originally held for
her GI bleed and they were restarted on 10/24/06 with systolic
blood pressures remaining in the 120s to 130s.
Rhythm: The patient has atrial fibrillation with slow
ventricular response with heart rates as low as the upper 30s.
Occasionally , her heart rate appeared regular and was thought to
be junctional escape rhythm. She was asymptomatic throughout her
hospitalization. She was discussed with her cardiologist , Dr.
Meduna , who will consider a pacemaker as an outpatient.
4. Endocrine: She is euthyroid with TSH of 2.422. For her
diabetes , she received nightly Lantus with aspart before every meal and
sliding scale when eating and Regular insulin sliding scale every 6 hours
when npo Fingersticks were elevated to 300s early during this
admission but improved to the 100s upon increasing her insulin
dose.
5. Musculoskeletal: The patient is status post right total hip
replacement approximately 13 years ago and complained of right
hip pain upon admission. An x-ray showed stable arthroplasty and
the pain was improved by the morning of 10/24/06 .  She will
follow with physiatrist , Dr. Ma Yeagley .
COMPLICATIONS: Right hand weakness , numbness , and coolness
status post AV fistula surgery , possibly secondary to steal or
neurapraxia , significantly improved by the time of discharge.
CONSULTANTS: Dr. Stacie Halechko from vascular surgery , Dr. Jeana Osdoba from gastroenterology.
PHYSICAL EXAMINATION ON DISCHARGE: Stable vital signs. Lungs
with bibasilar crackles. 3/6 systolic murmur heard throughout
plus a mechanical S2. Abdomen benign. Lower extremities with
chronic venous stasis changes. Right upper extremity AV fistula
with +thrill. Decreased right radial pulse with warm
hand distally , and 4/5 strength in hand grip of the right hand.
DISCHARGE MEDICATIONS: Norvasc 5 mg daily , Caltrate plus D one
tablet orally twice a day , Aranesp 25 mcg subcutaneously weekly , Lovenox 50 mg
subcutaneously daily starting on Thursday 12/10/06 ( to be discontinued when patient's
INR is therapeutic on coumadin ) , Nexium 40 mg orally
twice a day , ferrous sulfate 325 mg orally twice a day , Lasix 160 mg orally
daily , insulin aspart 5 units subcutaneously every meal , insulin Lantus 15
units subcutaneously every afternoon , Imdur 30 mg orally twice a day , sevelamer 400 mg
orally before every meal , multivitamin one tablet daily , valsartan 120 mg orally
daily , and Coumadin 4 mg orally every afternoon starting on Thursday
12/10/06 .
DISPOSITION: To home with services.
FOLLOW-UP APPOINTMENTS: The patient will follow up with Dr. Ardella S Norseth in one to two weeks , with Dr. Halechko from vascular surgery
on 5/5/06 at 8:30 a.m. , with Dr. Ma Yeagley from physiatry
on 11/29/06 at 10 a.m. , and Dr. Doris Meduna on 7/9/07 at
11:45 a.m.
CODE STATUS: The patient is full code , and her healthcare proxy
is her daughter , Almeda Leveto .
PRIMARY CARE PHYSICIAN: Ardella Norseth , MD.
eScription document: 1-2024642 CSSten Tel
Dictated By: RODERMAN , LIZETH
Attending: CASEBIER , WERNER REGINIA
Dictation ID 1307929
D: 10/15/06
T: 10/10/06

Document id: 2

380365284 | PUO | 78244363 | | 6836478 | 11/29/2005 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 9/10/2005 Report Status: Signed

Discharge Date:
ATTENDING: PETTINGER , DOUGLASS MD
DATE OF DISCHARGE: Not known at the time of this interim
dictation.
SERVICE: I Car Health Center .
PRIMARY DIAGNOSIS: Congestive heart failure.
SECONDARY DIAGNOSES: Postpartum cardiomyopathy status post
mitral valve repair , status post tricuspid valve repair , status
post ICD/pacer placement , asthma , and anemia.
HISTORY OF PRESENT ILLNESS: This is a 33-year-old female with a
history of postpartum cardiomyopathy ( EF 15% to 20% ) , status post
pacer/ICD placement , status post mitral valve
replacement/tricuspid valve replacement , who presents with
abdominal pain , decreased appetite , nausea , vomiting , and
occasional chest pain. The patient has had multiple recent
admissions to Pagham University Of .  In October 2005 , the
patient presented with chest pain and was found to be in
decompensated heart failure. She ruled out for myocardial
infarction. She was diuresed with torsemide. A MIBI prior to
this admission in October 2005 had showed no evidence of
ischemia. The patient was more recently readmitted in July
2005. During this admission , she underwent mitral valve repair
and tricuspid valve repair given severe mitral regurgitation and
tricuspid regurgitation. She had a catheterization on 6/12/05 ,
which showed normal coronary arteries , no equalization of
diastolic pressures , pulmonary capillary wedge pressure of 19 ,
and 4+ mitral regurgitation. A TTE during this admission showed
an EF of 15% to 20% with wall motion abnormalities. She had mild
right ventricular enlargement and decreased right ventricular
function. Pulmonary artery systolic pressure was 16 plus right
atrial pressures. She was also found to have a 1.5-cm
pericardial effusion. On this admission , the patient's primary
complaints involve decreased appetite , nausea , vomiting , and
abdominal pain. The patient reports frequent vomiting after
meals. The vomitus is nonbloody and nonbilious. The patient
denies diarrhea , in fact , she has been constipated. Her last
bowel movement was on the day of admission , but she did not have
a bowel movement four to five days prior to this time. She
denies fever or chills. She denies dysuria or hematuria. She
denies melena or bright red blood per rectum. She reports
intermittent shortness of breath , which she believes to be her
baseline. She denies weight gain , orthopnea , or PND. The
patient reports occasional tightness in her left chest , which
occurs a few times each week. There are no associated ischemic
symptoms. The pain is nonexertional and it is pleuritic. In the
emergency room , the patient was afebrile with a pulse of 97 and a
blood pressure of 98/58. Her cardiac enzymes were negative x1.
A PE protocol CT was negative for pulmonary embolus. The patient
was noted on this CAT scan to have a pericardial effusion. The
patient was seen by the Cardiology Service who performed a
bedside echocardiogram , which showed effusion , but no evidence of
right atrial or right ventricular collapse.
PAST MEDICAL HISTORY:
1. Congestive heart failure.
2. Postpartum cardiomyopathy , October 2004.
3. Asthma.
4. Status post mitral valve repair , status post tricuspid valve
repair , 9/16/05 .
5. Status post pacer/ICD placement in October 2005.
6. Chronic cough.
7. History of HIT positivity.
8. Status post C-section.
ALLERGIES: The patient has a history of HIT.
MEDICATIONS: Digoxin 0.125 mg orally daily , Colace , Niferex 150 mg
twice a day , Aldactone 25 mg daily , Toprol-XL 25 mg daily , K-Dur 20
mEq twice a day , torsemide 100 mg orally every day before noon , 50 mg orally every afternoon ,
Advair , Nexium 20 mg orally daily , and Coumadin ( unclear if the
patient is taking Coumadin ).
SOCIAL HISTORY: The patient lives with her aunt and her
children. She has a visiting nurse. She denies tobacco or
alcohol use.
FAMILY HISTORY: Remarkable for breast cancer.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 96.6 , pulse 70 ,
blood pressure 80/60 , respirations 18 , O2 sat 96% on 2 liters.
The patient has no pulses ( 8 mmHg ). The patient is alert and in
no acute distress. She is dysphoric. Her pupils are equal and
reactive to light. Extraocular movements intact. Oropharynx
clear. JVP is 10 cm. There is no Kussmaul's sign. Heart has a
regular rate and rhythm. Normal S1 , S2 with 1/6 holosystolic
murmur at the apex. No S3 or S4 were noted. Lungs are clear to
auscultation bilaterally. Abdomen is soft , nontender ,
nondistended with normoactive bowel sounds. There is no rebound
or guarding. There is no costovertebral angle tenderness.
Extremities: The patient has trace edema bilaterally. She is
warm and well perfused. She has no calf tenderness. She is
alert and oriented x3. Her cranial nerves are intact. She has
5/5 strength throughout. Her affect is dysphoric.
LABORATORY ON ADMISSION: Remarkable for a potassium of 2.8 , BUN
6 , creatinine 0.7 , white count 10.43 , hematocrit 30.1 , platelets
423 , 000 , MCV is 79.4 , INR is 1.4 , PTT 30.9. D-dimer is 3273
despite the negative LENIs and negative PE protocol CT. First
set of cardiac enzymes is negative. EKG shows normal sinus
rhythm at 92 beats per minute with a normal axis. There are
occasional PVCs. There is T-wave inversion/flattening in V2
through V6 as well as leads I , aVL , II , III , and aVF. Urinalysis
shows trace leukocyte esterase , negative nitrites , 4 to 8 white
blood cells , no red blood cells , and 1+ bacteria. Urine hCG is
negative. Chest x-ray shows stable cardiomegaly without
pulmonary edema or infiltrate.
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular:
a. Ischemia. The patient reported chest pain on admission. The
chest pain was atypical for ischemia and that it was
nonexertional. It was pleuritic and it had no associated
ischemic symptoms. In addition , the patient had normal
coronaries on a recent catheterization in 3/22 as well as a
nonischemic MIBI in October 2005. The patient's enzymes were
negative on this admission. The patient was continued on her
beta-blocker.
b. Pump. The patient has a postpartum cardiomyopathy with an
ejection fraction of 15% to 20%. She also has a pericardial
effusion on this admission. On admission , there was no evidence
of tamponade by exam or by echocardiogram. The patient had a
repeat TTE on 10/18/05 , which showed pericardial effusion , which
was slightly larger than that seen in July 2005. There was
respirophasic variation , but no collapse. The patient's urine
output decreased on 8/26/05 and she underwent right heart
catheterization , which showed extremely elevated right and left
filling pressures ( pulmonary capillary wedge pressure in the 40s ,
right atrial pressure 27 ). The patient was initially placed on a
Lasix drip. She was also started on intravenous dobutamine to maintain
her blood pressure and for perfusion while being diuresed. After
a few days on this regimen , the patient had a repeat right heart
catheterization , which showed improved , but elevated left and
right filling pressures. A Swan catheter was left in place for
closer monitoring of the patient's hemodynamics and to allow for
tailored therapy. At the time of this dictation , the patient
will be tried on various inotropes including dopamine and
dobutamine with close monitoring of her hemodynamics. The
purpose of this is to assess the effect of these inotropes on her
hemodynamics , so there would be a time when she requires inotrope
therapy at home. The patient was also maintained on digoxin.
Her Aldactone was changed to eplerenone given the possibility
that Aldactone could be contributing to the patient's GI
complaints. At the time of this dictation , there is a plan in
place to try to add hydralazine/Isordil to the patient's regimen
for afterload reduction if her blood pressure can tolerate this.
In the past , the patient had suffered severe hypotension when
such medications have been added.
c. Rhythm. The patient is status post pacer/ICD placement. She
was monitored on telemetry. Her telemetry will be followed
closely for any evidence of ectopy while on dobutamine or
dopamine.
2. Pulmonary: The patient has a history of chronic cough. Past
chest CTs have shown ground-glass opacities most likely due to
edema , which have resolved on more recent imaging. Pulmonary
function test in July 2005 showed an FEV1 of 2.06 , FEV1/FVC of
102 , total lung capacity of 3.09 , and a DLCO corrected of 54%
predicted. The patient was continued on Advair and was given
Atrovent as needed As mentioned previously , a PECT on admission was
negative.
3. Renal/FEN: The patient has hypokalemia in the setting of
diuresis. Her electrolytes were monitored twice a day and repleted as
needed. The patient's creatinine remained stable less than 1
throughout her admission. The patient was maintained on a
low-salt , food-restricted diet.
4. GI: The patient presented with a number of GI complaints
including abdominal pain , nausea , vomiting , and anorexia. It is
not clear what the cause of these symptoms is. The patient had
normal liver function tests. She had a KUB , which showed no
obstruction. Her urine culture showed no evidence of urinary
tract infection. It is possible that abdominal pain was due to
constipation or as a side effect of Aldactone or even to a low
flow state in the setting decompensated heart failure. The
patient was continued on a bowel regimen and a proton pump
inhibitor. At the time of this dictation , the patient's
abdominal complaints have resolved.
5. Heme: The patient has a history of iron-deficiency anemia.
On admission , her hematocrit was 30 with a MCV of 79.4. The
patient takes iron supplementation at home. This was held
temporarily in the setting of constipation. The patient also
takes Coumadin for a low ejection fraction. This is also placed
on hold in the setting of various procedures including her right
heart catheterizations and PA catheter placement. It should be
noted that the patient has a history of HIT positive.
6. ID: On 9/15/05 , the patient had a temperature of 100. This
was status post placement of a PA catheter. There was concern
for a line infection. Blood cultures were drawn and the patient
was started on vancomycin. At the time of this dictation , blood
cultures showed no growths to date , but should continue to be
followed.
7. Psych: The patient has a history of depression. She
appeared dysphoric on admission , but denied any suicidality.
Both Psychiatry and Social Work were contacted who followed the
patient during this admission and who have followed the patient
on previous admission. The Psychiatry Service had recommended
Remeron for sleep , which the patient was given with good effect.
8. Prophylaxis: The patient was given Pneumoboots early on in
her admission and then was out of bed several times each day.
She was also given a proton pump inhibitor.
9. Code: The patient is full code.
The events that occur after the time of this dictation , the
disposition , discharge condition , followup , and discharge
medications will be dictated in an addendum to this discharge
summary.
eScription document: 1-2096456 ISFocus transcriptionists
CC: Douglass Pettinger MD
Kee , Washington
Dictated By: CONEDY , ARMINDA
Attending: PETTINGER , DOUGLASS
Dictation ID 8946563
D: 7/18/05
T: 7/18/05

Document id: 3

381800224 | PUO | 26149384 | | 6808586 | 5/26/2006 12:00:00 a.m. | PNUEMONIA | Signed | DIS | Admission Date: 4/22/2006 Report Status: Signed

Discharge Date: 7/27/2006
ATTENDING: YEAROUS , MARICA MD
SERVICE:
Medicine Service.
ADMISSION INFORMATION AND CHIEF COMPLAINT:
Hypoxemic respiratory failure.
HISTORY OF PRESENT ILLNESS:
The patient is a 57-year-old woman with a past medical history of
OSA , asthma , CAD status post CABG. On 8/19/06 , she underwent a
right total knee replacement at Pagham University Of .  On
8/9/06 , she was discharged to rehabilitation. There , she
experienced fever , cough and dyspnea. She was started on
vancomycin , ceftazidime , and Flagyl for presumed pneumonia. In
the PUO ED , the patient was afebrile with a temperature of 97.6 ,
pulse of 88 , blood pressure 117/70 , oxygen saturation 97% on 6
liters nasal cannula. Her exam was notable for crackles in the
left base and 1+ lower extremity edema.
ADMISSION LABS:
Notable for white blood cell count of 20 , hematocrit 3of 5 ,
platelets of 442 , 000 , creatinine of 0.6 , and INR of 1.2. Her
admission EKG revealed sinus tachycardia of 119 beats per minute ,
normal axis , QRS 104 milliseconds , QTC 461 milliseconds , no
evidence of atrial enlargement or ventricular hypertrophy , poor
R-wave progression , 2 mm ST depressions and T-wave inversions in
leads 1 , aVL , V5 , V6 , 1 mm J-point elevation in V3 ( prior EKG
showed T-wave inversions in 1 , and aVL with no ST depressions ).
Her admission chest x-ray revealed bilateral diffuse patchy
opacities.
The patient was presumed to have pneumonia versus CHF. She was
treated with vancomycin , cefotaxime , levofloxacin , and
azithromycin , and was admitted to the Medicine Service for
further evaluation and management.
PAST MEDICAL HISTORY:
1. Left carotid artery stenosis status post CEA.
2. Right carotid artery stenosis , status post angioplasty.
3. OSA.
4. Asthma.
5. CAD status post three-vessel CABG in 2004 and subsequent PCI
to the ramus in 2005.
6. 70-80% RCA stenosis not bypassed during CABG.
7. Hypertension.
8. CHF , ejection fraction 45-50%.
9. AS status post aortic valve replacement.
10. Pericarditis removal.
11. Diabetes.
12. Peripheral vascular disease.
MEDICATIONS AT REHAB:
1. Vancomycin 1 gram intravenous every 12 hours , ( first dose 27 of March ).
2. Ceftazidime 1 g intravenous every 8 hours , ( first dose 7/17/06 )
3. Flagyl 500 mg intravenous every 8 hours , ( first dose 7/17/06 .
4. Advair 100/50 inhaled twice a day
5. Aspirin 325 mg orally daily.
6. Lipitor 80 mg orally at bedtime.
7. Zetia 10 mg orally daily.
8. Lopressor 75 mg orally every 6 hours
9. Lasix 1 tablet orally daily.
10. Colace 100 mg orally twice a day
11. Multivitamin 1 tab orally daily.
12. CaCO3 500 mg orally daily.
13. Cholecalciferol 400 units orally daily.
14. Ferrous sulfate 300 mg orally three times a day
15. Folic acid 1 mg orally daily.
16. Avapro 225 mg orally daily.
17. Lantus 100 units subcutaneously daily.
18. Lispro sliding scale.
19. Coumadin.
20. P.r.n. oxycodone , Tylenol , Benadryl , and Metamucil.
ALLERGIES:
Lisinopril leads to cough and metformin leads to GI distress.
SOCIAL HISTORY:
The patient was formerly employed as a cashier. She has two
children. She is a former cigarette smoker. She does not use
alcohol.
FAMILY HISTORY:
The patient has a positive family history of coronary disease ,
hypertension and diabetes.
HOSPITAL COURSE BY SYSTEM/ PROBLEM:
Persistent pulmonary
1. Hypoxemic respiratory failure. On 1/7/06 , shortly after
her admission to the medical floor , the patient was noted to be
in respiratory distress with tachypnea , accessory muscle use and
oxygen saturation of 68% on 6 liters nasal cannula. She was
placed on a nonrebreather. Her oxygen saturation increased to
93%; however , she continued to be in respiratory distress with
tachypnea and accessory muscle use. She was intubated and
transferred to the Medical Intensive Care Unit for further
evaluation and management. Her respiratory failure was thought
to be secondary to pneumonia with a component of superimposed
volume overload. She was treated with a 10-day course of
vancomycin , levofloxacin and ceftazidime as well as with intravenous
Lasix. She underwent a code green on 7/30/06 during an ETT tube
change , wherein a patent airway was transiently loss. The
patient was slow to wean from the ventilator. Her chest imaging
revealed persistent bilateral opacifications. It was thought
that after an initial infectious insult , the patient developed
ARDS. On 9/14/06 , the patient underwent bronchoscopy and BAL
revealing MRSA and HSV. The patient was treated with a 10-day
course of acyclovir for presumed HSV tracheobronchitis. Given
her inability to be weaned from the vent , the patient underwent a
tracheostomy on 4/17/06 .  Post-tracheostomy , the patient
alternated between pressure support ventilation with low driving
pressure and PEEP with a trach collar..
Infectious disease:
1. Fevers. From 1/7/06 to 7/28/06 , the patient was treated
with vancomycin , levofloxacin and ceftazidime for hospital
acquired pneumonia. After discontinuation of her antibiotics ,
the patient continued to spike fevers and evidence of
leukocytosis. In verification into source of her fevers included
serial blood cultures , urine cultures and C-dif. Positive data
included: 7/28/06 , urine culture with yeast , 7/28/06 , blood
culture with coag-negative staph , 9/14/06 BAL washings with HSV ,
9/14/06 , blood culture with coag-negative staph , 7/11/06 , blood
culture with coag-negative staph , 2/29/06 , urine culture with
yeast , 2/29/06 BAL washings with MRSA , 10/28/06 urine with yeast
urine with yeast , 10/28/06 , 6/23/06 , 4/17/06 , and 10/11/06
sputum with MRSA. 7/28/06 , chest CT with bilateral
opacification in the lung parenchyma. 2/29/06 facial CT with
left sphenoid maxillary thickening. 2/29/06 chest CT with
bilateral opacification in the lung parenchyma. Of note , a
2/29/06 abdominal CT showed no evidence of abdominal infection ,
2/29/06 TTE showed no obvious vegetations , and 10/11/06 tap of
the right knee grew no organisms. In light of the data above ,
the patient's indwelling catheters were changed. She underwent
treatment with linezolid x7 days for MRSA line infection. She
also underwent treatment with acyclovir x10 days for HSV
tracheobronchitis. The aforementioned antibiosis was mostly
prophylactic. It was thought that the patient's intermittent
fevers were not infectious , but rather reflected a drug allergy ,
most likely to vancomycin. This hypothesis was supported by a
robust eosinophilia coinciding with vancomycin administration.
Shortly after vancomycin discontinuation , the patient's fevers
resolved. The patient was afebrile for greater than 48 hours off
all antibiotics prior to transfer to rehabilitation.
Cardiovascular:
1. Volume status. The patient's admission weight was 106.2 kg.
It is unclear what her dry weight was. Given that pulmonary
edema was thought to be contributing to the patient's slow
ventilator wean , she was diuresed with a combination of Lasix and
Diuril followed by combinations of torsemide and Diuril. Her
discharge weight was 100.7 kilograms. Her diuretic regimen on
discharge with torsemide 100 mg intravenous three times a day and Diuril 500 mg intravenous
three times a day The patient's diuretic regimen will need be adjusted as
her intake is adjusted. Her creatinine will need to be monitored
very closely. Her weight will need to be checked daily.
2. Pump: The patient underwent echocardiogram on 11/19/06 ,
7/17/06 , and 2/29/06 .  On the whole , these studies revealed an
ejection fraction of 45-50% , concentric LVH , global hypokinesis
with regional variation , mild left atrial enlargement , mild
tricuspid regurgitation , a question of mild atrial stenosis , and
pulmonary artery pressures in the 40s. For her heart failure ,
the patient was treated with Lopressor and diuretics as above.
She was not started on an ACE inhibitor given her allergy
( cough ). She was started on low-dose ARB.
3. Ischemia: The patient has a history of coronary artery
disease status post three-vessel CABG and subsequent
single-vessel PPI. She has an RCA stenosis , 70-80% that has not
intervened upon. On admission , in the setting of respiratory
distress , the patient was in sinus tachycardia with rate related
to lateral ST depressions. Her cardiac biomarkers were positive
consistent with NSTEMI. It was thought that the patient
experienced demand ischemia rather than an acute plaque rupture.
On 10/8/06 , her troponin peaked at 8.53 , her CK at 275 , and her
MB of 16.3. The patient was treated with aspirin , Lopressor , and
Zocor. She was not started on an ACE inhibitor as detailed
above. She will likely warrant Cardiology followup with possible
RCA revascularization.
Neuro:
1. Sedation: While intubated , the patient was treated with intravenous
Versed and fentanyl titrated to light sedation. After her
tracheostomy , the patient's Versed and fentanyl drips were
discontinued. She was treated with Seroquel at bedtime to
preclude nighttime agitation. Her QTC should be monitored while
on Seroquel.
GI:
1. FEN: The patient initially received tube feeds via feeding
tube. She underwent a PEG placement on 4/17/06 .  She continued
on tube feeds. She also passed speech and Swallow and was thus
started on orally feeds with aspiration precautions. She also
received supplemental multivitamins , calcium carbonate , and
cholecalciferol. The patient will require speech and swallow
evaluation at rehabilitation. Now that she is awake , she may be
able to tolerate orally feeds with aspiration precautions.
2. Bowel regimen. The patient was treated with Colace , senna ,
and Dulcolax.
Heme:
1. Anemia: The patient has known iron deficiency anemia. She
was continued on iron and folate. She may benefit from an
outpatient colonoscopy if she has not had one recently.
2. Bleeding from tracheostomy site: On 4/24/06 , the patient
was noted to have bleeding from her tracheostomy site. She had
no hematocrit drop. She remained hemodynamically stable. She
underwent a bronchoscopy , which showed no active bleeding. Her
mild bleeding was thought to relate to suction trauma. Her
prophylactic heparin was held x1 day. It was thought that the
patient should be discharged on prophylactic heparin because her
DVT risk is so high. Should the patient have intense bleeding
from the tracheostomy site , a hematocrit drop or hemodynamic
changes. Her heparin subcutaneously should be discontinued , her
hematocrit should be monitored closely , and she should be
transfused as needed. She should also at that point probably
undergo reevaluation by Pulmonary or Thoracics.
Endocrine:
1. Diabetes: The patient was treated with Lantus plus regular
insulin every 6 hours plus sliding scale insulin while she was on tube
feeds. Her insulin was changed on the night prior to discharge.
She was started on Lantus 100 subcutaneously twice a day She got her first dose
of 100 units subcutaneously on the evening prior to discharge , her morning
sugars were in the mid 100s. Her blood sugars should be followed
closely on the first one or two days at rehab. The blood sugars
should be monitored every 2-3 hours and her insulin should be
adjusted accordingly. Her insulin dose should be adjusted if her
tube feeds are cycled rather than given continuously or if she is
NPO.
Ortho:
1. Total knee replacement: The patient is status post right
total knee replacement on 8/19/06 .  Her right knee has a
well-healed incision and is not erythematous or tender. The
patient was initially on low-dose anticoagulation with Coumadin.
Her Coumadin was discontinued given her acute illness and her
need for procedures. She was treated with heparin subcutaneously
prophylactic doses 5000 units three times a day as described above. She
will need rehabilitation for her knee.
2. Prophylaxis: The patient was treated with subcutaneous
heparin and Nexium.
3. Access: The patient has peripheral IVs.
DISCHARGE STATUS:
On the day of discharge 3/8/06 , the patient was afebrile.
Heart rate was in the 80s , blood pressure was in the
100s-130s/60s-80s. Discharge weight was 100.7 kilograms. The
patient was drowsy , but arouseable. She was breathing on a trach
collar. She had decreased breath sounds at the bases. She had
an S1 and S2 with a 2/6 systolic murmur at the lower sternal
border. Her abdomen was soft and nontender with positive bowel
sounds. Her trach and PEG site were intact without any
surrounding erythema. Her extremities were warm without edema.
She was on trach collar with 50% FiO2 and oxygen saturation of
97%. Her discharge labs included a white blood cell count of 21 ,
stable , hematocrit of 28 , and platelets 436 , 000. Her chem-7
included a sodium of 131 , potassium 3 , chloride 87 , CO2 32 , BUN
67 , creatinine 0.8 , and glucose 154. Her LFTs were normal. Her
INR was 1.1. Her most recent microdata showed sputum with few
polys and a few gram-positive cocci in clusters. Her chest x-ray
showed a trach in place and bilateral hazy infiltrate consistent
with resolving ARDS.
An addendum will be given with discharge medications and doses.
At rehab , the patient's weight should be monitored daily. Her
blood sugars initially be monitored every 2-3 hours. After that ,
her blood sugar monitoring can be spaced out to three times a day or
whenever deemed appropriate by the physician at the
rehabilitation facility. Her hematocrit should be checked
particularly if she has any bleeding from her tracheostomy site;
otherwise , the hematocrit can be checked every day. The white
blood cell count should be monitored if the patient has any
fever. The creatinine should be monitored daily in light of the
patient's changing diuretic regimen. The patient in's and out's
should be monitored closely.
CONTACTS AT THE HOSPITAL:
Totin Hospital And Clinic regarding the patient's inpatient course or
Dr. Marica Yearous . Contacts regarding follow up issues , the
patient's primary care physician , Dr. Erma Dovie Bess at Flofry Bradlrel Memorial Hospital 888-043-9980. The patient's healthcare proxy is her
sister , Miquel Fry who is a registered nurse , her telephone
number 743-396-9384 at home and 528-513-0528 cell phone.
eScription document: 6-0610820 EMSSten Tel
CC: Erma Dovie Bess MD
A
CC: Marica Yearous MD
Dictated By: TROOP , WILFREDO
Attending: YEAROUS , MARICA
Dictation ID 5934052
D: 3/8/06
T: 3/8/06

Document id: 4

853274428 | PUO | 67747717 | | 716666 | 3/29/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 3/29/1993 Report Status: Signed

Discharge Date: 12/10/1993
PRINCIPLE DIAGNOSIS: CORONARY ARTERY DISEASE.
OTHER DIAGNOSES: PERIPHERAL VASCULAR DISEASE ,
HYPERTENSION.
ALLERGIES: No known drug allergies.
HISTORY OF PRESENT ILLNESS: The patient is a 70 year old male
immigrant from Ma Gosatope
with a long history of angina. He had been followed in the Sungooaks Van Heim , Iowa 05164 for years with strong indication for interventional
evaluation of his coronary artery disease. The patient had refused
and had been being treated medically inspite of the angina pattern.
Recently his angina had worsened and he agreed to undergo more
intensive workup. He was referred for elective cardiac
catheterization. PAST MEDICAL HISTORY: Hospitalization for an
episode of chest pain in Voboville , hypertension and history
of peripheral vascular disease with claudication symptoms.
PHYSICAL EXAMINATION: On physical exam the patient's temperature
was 97.7 , heart rate 60. HEENT: Head and
neck exam unremarkable. Lungs: Clear anteriorly. Heart: Regular
rate and rhythm , no murmurs appreciated. Abdomen: Soft , non-tender.
EXTREMITIES: No edema. Had weakly dopplerable pulses. Of note , his
physical exam was performed on his emergent admission to the
cardiac care unit after becoming unstable at elective cardiac
catheterization.
LABORATORY EXAMINATION: His admission laboratory exam was
remarkable for a normal CBC and serum 20
general exam. His EKG after cardiac catheterization demonstrated
inverted T waves in III , F and some ST depression in V4-V6.
HOSPITAL COURSE: On elective cardiac catheterization the patient
was noted to have a 90% ostial left anterior
descending coronary artery lesion. He had EKG changes ,
symptomatically had chest pain at catheterization. He was referred
for emergent coronary artery bypass grafting. An intra-aortic
balloon pump was placed. He was taken emergently to the Operating
Room where a 4 vessel coronary artery bypass was performed. There
were no intraoperative complications. Postoperatively , the patient
did remarkably well inspite of his dramatic presentation. He had
no vascular complications. His intra-aortic balloon pump was
removed without incident and he had no specific cardiopulmonary
complications. His only issue at discharge was urinary retention.
He failed several voiding trials. Urology Service had consulted and
felt this was likely secondary to benign prostatic hypertrophy.
DISPOSITION: He was discharged home with an indwelling Foley
catheter with follow-up arranged at CHH Urology.
MEDICATIONS: His discharge medications include aspirin 1 a day ,
iron , Colace , Mevacor 20mg every day and Tylenol #3 as needed He will
follow-up with his Cardiologist , urology service and with cardiac
surgery.
Dictated By: MOSHE J. SHUGRUE , M.D. HV78
Attending: DESIRAE R. MARCOTT , M.D. NM7  AV931/1170
Batch: 9267 Index No. D9IIBT325W D: 2/13/94
T: 2/13/94

Document id: 5

888816163 | PUO | 23256318 | | 2723475 | 9/25/2006 12:00:00 a.m. | CONGESTIVE HEART FAILURE | Unsigned | DIS | Admission Date: 1/8/2006 Report Status: Unsigned

Discharge Date: 7/16/2006
ATTENDING: KERTESZ , ALETA M.D.
SERVICE:
Cardiac Surgery Service.
HISTORY OF PRESENT ILLNESS:
Mr. Lemick is a 64-year-old gentleman with a previous history of
myocardial infarction x4 who presented to the Emergency
Department on 3/10/06 with shortness of breath and dyspnea on
exertion over the previous two months. The patient has known
coronary artery disease and has undergone multiple PTCAs and
balloon angioplasties in the past of his posterior descending branch
of his right coronary artery in 1996 , and stenting of his
posterior descending coronary artery in 2004 , also stenting of
his distal right coronary artery in 2005. While in the emergency
department , the patient had an episode of substernal chest
pressure radiating to his left jaw and left upper extremity. He
received sublingual nitroglycerin and morphine with relief. EKG
at that time revealed a right bundle-branch block with T-wave
inversions in the leads V2 , V3 , and slightly T-wave elevation in
leads II , III and aVF. On 1/5/06 , he underwent cardiac
catheterization , which revealed the following , posterior
descending coronary artery with an ostial 80% stenosis , right
coronary artery with a distal 60% stenosis , left circumflex
coronary artery with the proximal 60% stenosis , left anterior
descending coronary artery with an ostial 50% stenosis. Right
dominant circulation and right coronary artery had extensive
stenting with 50-60% focal areas of restenosis. Distal right
coronary artery stent before bifurcation has 80% stenosis.
Echocardiogram revealed an ejection fraction of 50% aortic
stenosis with a mean gradient of 41 mmHg and peak gradient of 60
mmHg , calculated valve area is 1 cm2 , mild aortic insufficiency ,
moderate mitral insufficiency , moderate tricuspid insufficiency ,
and mild pulmonic insufficiency. Carotid ultrasound revealed
right internal carotid artery with a 1-25% stenosis , left
internal carotid artery with a 1-25% stenosis. Pulmonary
function tests revealed FVC of 3.11 , 53% , and an FEV1 of 1.66 ,
35% predicted. Chest CT also performed on 5/29/06 revealed
cardiomegaly , massive calcifications involving the aortic valve
and coronary arteries , pleural thickening bilaterally , nodular
density measuring 7 mm in the lateral basal segment of the left
lung most likely represents round atelectasis or focal pleural
thickening , however , subpleural nodule cannot be excluded ,
recommending a repeat chest CT in six months after discharge , and
small ascites punctate calcifications in the pancreas.
PAST MEDICAL AND PAST SURGICAL HISTORY:
Significant for myocardial infarction , class II angina with
slight limitation of ordinary activity , class III heart failure
with marked limitation of physical activity , status post a PTCA
atherectomy and stent placement , hypertension ,
non-insulin-dependent diabetes mellitus , dyslipidemia , gout ,
anemia , positive PPD , status post inhaled treatment , herniated disk ,
history bladder cancer , status post chemotherapy treatment ,
polysubstance abuse including ethanol and tobacco , narcotics , and
intravenous drug abuse. He is also status post a left thoracotomy for
pleural effusion 30 years ago , a hemorrhoidectomy , and bilateral
hand surgeries for contractures.
ALLERGIES:
The patient has no known drug allergies.
MEDICATIONS AT TIME OF ADMISSION:
Atenolol 50 mg once a day , lisinopril 20 mg once a day ,
isosorbide 30 mg daily , aspirin 325 mg daily , Plavix 75 mg daily ,
Lasix 40 mg daily , atorvastatin 80 mg daily , gemfibrozil 600 mg
twice a day , metformin 1 g twice a day , glimepiride 2 mg daily , oxycodone
10 mg every 6 hours as needed for pain , and Nexium 20 mg daily.
PHYSICAL EXAMINATION:
Cardiac exam: Regular rate and rhythm , with a grade 2/6 systolic
ejection murmur at the right upper sternal border. Peripheral
vascular , 2+ pulses bilaterally in the carotid and radial pulses ,
1+ bilaterally in the femoral and dorsalis pedis pulses , and
nonpalpable bilaterally in the posterior tibialis pulses.
Respiratory: Breath sounds clear bilaterally. Extremities:
Mild varicosities. There is 1+ pedal edema in bilateral lower
extremities , otherwise , noncontributory.
ADMISSION LABORATORY VALUES:
Sodium 138 , potassium 3.8 , chloride 97 , CO2 32 , BUN 26 ,
creatinine 1.1 , glucose 66 , and magnesium 2. BNP is 2349. WBC
6.45 , hematocrit 31.6 , hemoglobin 9.9 , and platelets 192 , 000.
physical therapy/INR of 1.3 , PTT of 33.2.
HOSPITAL COURSE:
Mr. Lemick was brought to the operating room on 8/13/06 where
he underwent an elective aortic valve replacement with a 25 mm
Carpentier-Edwards magna valve and a coronary artery bypass graft
x2 with left internal mammary artery to left anterior descending
coronary artery , saphenous vein graft to the posterior descending
coronary artery. Total bypass time was 164 minutes. Total
crossclamp time was 127 minutes. Intraoperatively , the patient
was found to have a calcified trileaflet valve functionally was a
bicuspid due to effusion between the left and right cusp ,
moderate adhesions in the left pleural space , requiring
adhesiolysis to harvest the mammary artery. Transesophageal
echocardiogram post-repair revealed normal function of the aortic
prosthetic valve and mild mitral regurgitation , with intermittent
heart block following bypass predominantly with A pacing. The
patient did well intraoperatively , came off bypass without
incident , was brought to the Intensive Care Unit in normal sinus
rhythm and in stable condition. Please refer to dictation
number 6316454 for the immediate postoperative course. The
patient was transferred to the Step-Down Unit on 7/26/06 .  The
patient's mental status waxed and waned with confusion , initially
was with sitters in the Step-Down Unit , and also was in a
rate-controlled atrial fibrillation , with a good blood pressure ,
and tolerated increasing beta-blocker. The patient's mental
status improved , did well off sitters , and continue with
rate-controlled atrial fibrillation. Mr. Lemick was placed on
Coumadin for his atrial fibrillation. Neurologically , he
remained intact , and was placed on levofloxacin and vancomycin
for H. flu and Staph pneumonia , which are both sensitive to
Bactrim , and started on a 5-day course of Bactrim twice a day.
He was cleared for discharge to home on postoperative day #9.
DISCHARGE LABORATORY VALUES:
Sodium 137 , potassium 4.3 , chloride 99 , CO2 28 , BUN 18 ,
creatinine 0.9 , glucose 95 , and magnesium 1.7. WBC 12.07 ,
hematocrit 27.9 , hemoglobin 8.6 , and platelets 396 , 000. physical therapy of
19.3 , physical therapy/INR of 1.6.
DISCHARGE MEDICATIONS:
Captopril 12.5 mg three times a day , Colace 100 mg three times a day while taking
oxycodone , Prozac 40 mg daily , folate 1 mg daily , Lasix 40 mg
daily , Lopressor 25 mg four times a day , Niferex 150 mg twice a day , oxycodone
10 mg every 6 hours as needed pain , multivitamin with minerals one tab
daily , thiamine hydrochloride 100 mg daily , potassium chloride
slow release 10 mEq daily with his Lasix , Bactrim double strength
one tab every 12 hours for five days , Plavix 75 mg daily , Lipitor 80 mg
daily , and Coumadin , the patient received 6 mg of Coumadin this
evening for his atrial fibrillation. He will be followed by
Pagham University Of Anticoagulation Service at
132-202-5576.
FOLLOW UP:
Mr. Lemick will follow up with Dr. Aleta Kertesz in six weeks , his
cardiologist , Dr. Rodger Teems in one week in the Cardiology
Clinic Niy Lastan Stonevir Medical Center .  He will also have a
follow-up chest CT to follow up on the 7 mm subpleural nodular
density in the left lung base in approximately six months that
will be set up by his primary care physician and cardiologist.
DISPOSITION:
He is discharged to home in stable condition with visiting nurse.
eScription document: 9-6284140 EMSSten Tel
Dictated By: BARBELLA , PRISCILLA
Attending: KERTESZ , ALETA
Dictation ID 9473886
D: 1/2/06
T: 3/26/06

Document id: 6

718175239 | PUO | 85554562 | | 3074401 | 11/4/2005 12:00:00 a.m. | HEART FAILURE | Signed | DIS | Admission Date: 5/7/2005 Report Status: Signed

Discharge Date: 10/8/2005
ATTENDING: HAUB , PERRY M.D.
CHIEF COMPLAINT:
This is a 64-year-old woman with a history of nonischemic
cardiomyopathy who was admitted with increasing volume overload.
HISTORY OF PRESENT ILLNESS:
Ms. Englebert was doing well until approximately two weeks prior to
admission when in the setting of dietary indiscretion she noticed
some shortness of breath and weight gain. She states that she
started to increase her Demadex from 200 mg in the morning and
150 mg in the afternoon to 200 mg twice a day without significant
diuresis. She has continued to participate in cardiac rehab
without significant difficulty. Her weight was stable at 174.
She did , however , noticed worsening of intermittent dyspnea on
exertion and orthopnea , although she denied PND or pedal edema.
She denied abdominal symptoms of bloating , no satiety , nausea or
vomiting. She denied chest pain , discomfort , palpitations ,
lightheadedness or syncope. She does have occasional chest
burning. She also noted burning in her feet bilaterally which
has previously been attributed to neuropathy. On the day of
admission , she presented to the Outpatient Clinic to have an
echocardiogram and repeat exercise stress test with oxygen
uptake. She exercised for 4 minutes and 32 seconds achieving a
peak heart of 90 beats per minute with a blood pressure of 100/64
and stopping secondary to fatigue. Her peak oxygen uptake was
only 9 mL per minute despite on RER of 1.09. This is essentially
unchanged from a prior exercise stress test one year ago.
PAST MEDICAL HISTORY:
Includes nonischemic cardiomyopathy diagnosed in 1996 , with clean
coronary catheterization at that point. She has history of
hypertension , hypertriglyceridemia , and left bundle-branch block
status post ICD and pacemaker placement. Her pacer is
biventricular. She also has a history of urine bleeding. She
had a recent hysteroscopy and laparoscopy which were
unremarkable.
MEDICATIONS ON ADMISSION:
Included lisinopril 10 mg orally daily , Toprol 75 mg orally daily ,
Demadex 200 mg orally twice a day , Aldactone 25 mg daily , KCl 10 mEq
daily , allopurinol 100 mg daily , colchicine 0.6 mg daily and
Evista 60 mg daily.
ALLERGIES:
Penicillin.
PHYSICAL EXAMINATION:
She was afebrile with heart rate of 72 , blood pressure of 104/66.
Her weight was 174. Her JVP was at approximately 16 cm of water
with hepatojugular reflux to the angle of the jaw. Her carotid
upstrokes were brisk without bruits. Her lungs were clear to
auscultation bilaterally. Her cardiac exam was regular in rate
and rhythm with normal S1 and S2 and audible S3. She has 2/6
systolic murmur consistent with mitral regurgitation. Her
abdominal exam was benign except for liver edge that is palpable
approximately two fingerbreadths below the costal margin. Her
extremities were noncyanotic with no clubbing or edema. They
were lukewarm.
SOCIAL HISTORY:
Unremarkable.
FAMILY HISTORY:
Noncontributory.
LABORATORY DATA:
Her most recent labs had showed a sodium of 138 , a potassium 3.9 ,
a BUN of 67 , a creatinine of 1.9 and glucose of 123. Her LFTs
were all normal except for mildly elevated bilirubin of 1.3. Her
last lipids showed a total cholesterol of 128 with 191
triglycerides and HDL of 31 and an LDL of 59. Her last CBC was
unremarkable. Her EKG shows an a-sensed V-paced rhythm at the
rate of 72 beats per minute.
HOSPITAL COURSE BY SYSTEMS:
Cardiovascular: Ms. Englebert is a 64-year-old female with
nonischemic cardiomyopathy and class II-III symptoms who
presented with worsening volume overload in the setting of
dietary indiscretion. Given that she is already maximized on her
outpatient diuretic dose and somewhat worsening of her renal
function , she was admitted for further diuresis with intravenous
torsemide. She was also admitted for the beginning of her
transplant evaluation for potential cardiac transplant. She was
initially started on intravenous torsemide 200 mg twice a day with a goal of 1
to 2 liters of diuresis per day. She was continued on digoxin
and switched over from lisinopril and captopril. Her medications
were adjusted to optimize her diuresis and avoid hypotensive
episodes. She did go for a right heart cath on this
hospitalization that showed increased RA pressure of 14 and a
wedge pressure of 35-44 with V wave. Her cardiac index was
calculated at 1.38. Her SVR was calculated at 1600. Her mixed
venous O2 sat was between 52% and 60% when the readings were
repeated. Given that she appeared quite well and Lasix drip was
started to accelerate her diuresis. She was maintained on
tailored therapy including nitrates for afterload reduction and
the up titration of her captopril. She did have impressive
diuresis on Lasix drip. Her transplant workup at this time
included PFTs that showed an FVC of 2.64 , which his 86% predicted
an FEV1 of 1.82 , which is 75% predicted and FEV1 to FVC ratio of
69%. Her corrected DLCO was 14.6 , which was 56% of predicted.
She did have as well a carotid duplex ultrasound showing no
significant stenosis in either carotid artery. Her ankle
brachial indices were greater than 1 in both lower extremities
and her leg pulse volume recording was all entirely normal. Her
24-hour urine collection showed a value of 920 mg over the total
volume which was in the normal range. She did continued to
respond reasonable well to the diuresis with the exception of a
few episodes of asymptomatic hypotension. Her creatinine did
begin to bump marginally indicating that she had likely been
slightly over diuresed. She subsequently stabilized and was
discharged on a stable dose of diuretics including torsemide 100
mg orally twice a day
Her other discharge medications include captopril 25 mg three times a day ,
Isordil 20 mg three times a day , Claritin , Coumadin 5 mg daily , thiamine and
multivitamin , colchicine , magnesium , Evista , Aldactone 25 mg
daily , digoxin 0.125 mg daily and allopurinol 100 mg daily ,
Toprol-XL 25 mg daily.
She was discharged with plan for regular follow up with her
outpatient cardiologist.
eScription document: 5-4062108 EMSSten Tel
Dictated By: IVASKA , MELDA
Attending: HAUB , PERRY
Dictation ID 9185928
D: 7/7/05
T: 7/7/05

Document id: 7

789882744 | PUO | 49201190 | | 8401704 | 8/29/2005 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 1/23/2005 Report Status: Unsigned

Discharge Date:
ATTENDING: COLASAMTE , ISABELLE EVON MD
SERVICE:
The patient has been treated on Cardiac Surgery Service.
CHIEF COMPLAINT:
Heart failure.
HISTORY OF PRESENT ILLNESS:
Ms. Rosenblum is a 56-year-old female with past medical history
significant for obesity and idiopathic cardiomyopathy diagnosed
in 1990 with an EF of 15% who was admitted on 7/20/05 for
one-week history of lower extremity edema and worsening heart
failure. She was treated initially on the Medicine Service where
she was aggressively diuresed but was requiring increasing
pressors and progressing in her CHF despite transfer to the CCU
and appropriate management by the medical team. On 1/10/05 , a
transplant heart became available , and she proceeded to undergo a
heart transplant.
PAST MEDICAL HISTORY:
Diabetes , renal failure , gout and obesity.
PAST SURGICAL HISTORY:
Tubal ligation , gastric stapling for obesity , and a Hickman
placement.
MEDICATIONS AT HOME:
Lovenox 40 mg every daily , Lasix 30 intravenous continuously , dobutamine 5 intravenous
cutaneously , milrinone 0.3 mcg/kg/ minute , Colace 100 mg orally
twice a day , sliding scale insulin , metolazone 5 mg orally twice a day ,
probenecid 500 mg orally daily , thiamine 50 mg orally daily ,
vancomycin 1 gram intravenous twice a day MVI therapeutic one tab orally daily ,
carnitine 0.5 grams orally three times a day , and Celexa 30 mg orally daily.
HOSPITAL COURSE:
The patient was initially treated on the Medicine Service but on
1/10/05 was taken to the operating room by the Cardiac Surgery
Service for a heart transplant. For detailed description of the
operative procedure , please see the dictated OP note. The
patient tolerated the procedure and was transferred to the Fre ICU
in a critical condition.
ICU COURSE BY SYSTEMS:
Neurological: Initially , the patient was kept sedated on
propofol as well as intermittent fentanyl and Versed. As she was
weaned towards extubation , her sedating medications were weaned
and she was extubated while on Precedex due to her history of
anxiety. Her Precedex was eventually weaned off and she was
neurologically intact but frequently confused and often
disoriented. Over the next several days , has continued to wean
and she was restarted on her Celexa as well as Ativan for
agitation and anxiety. At the time of transfer , she is
neurologically intact with no focal neurological deficits and she
is no longer confused. She is awake , alert and oriented to
person , place and time and completely appropriate in her speech.
Cardiovascular: Shortly after her operation , she was felt to be
in profound right heart failure. She was started on milrinone
with successive treatment of her right heart failure. Over the
next several days , she was weaned off slowly her pressors and
underwent an echocardiogram which showed moderate-to-severe TR
and a large pericardial effusion with some indentation of the
right atrium with respiration. However , no pericardiocentesis
was performed as the patient was not clinically in tamponade.
She underwent a cardiac catheterization for right heart biopsy ,
the results of which are still pending. At the present time , she
is on diltiazem 15 mg orally every 8 hours for hypertension as well as
milrinone 0.2. Cardiology is following and plans to keep the
milrinone going for the time being.
Pulmonary. The patient was kept intubated for the first several
days while she was unstable and on pressors. However , as she
began to improve , we weaned towards extubation , and she was
successfully extubated. At the current time , she is able to
ambulate on room air and has no pulmonary issues.
GI: The patient was kept npo for the first seven days after
her operation. After her extubation , a Dobbhoff feeding tube was
inserted and she was started on tube feeds until she was able to
clear her speech and swallow. Upon clearing her speech and
swallow evaluation , she was started on minced food with thickened
liquids , which she tolerated with minimal signs or symptoms of
aspiration. She was advanced to a house diet with thickened
liquids and is now taking that well and having normal bowel
movements. She is on Nexium for GI prophylaxis.
GU: Initially , she was given a lot of fluid in order to wean her
pressors; however , she was diuresed aggressively after the first
two postoperative days for currently being on a Lasix drip or
receiving large bolus doses of Lasix. Her creatinine has trended
up minorly postoperatively to a current level of 1.8. She is no
longer receiving any diuretics and is just being managed by
keeping her I's and O's even. She is on no nephrotoxic
medications.
Heme: She is frequently anemic with her hematocrit often
trending downwards to levels as low as 20 or 21. She has been
transfused with multiple units of blood products and will be
transfused today one unit of packed red cells for a hematocrit of
21. She has been started on Niferex for iron therapy , and we are
considering the addition of erythropoietin. Otherwise , she is
stable and has no heme issues.
ID and Immunosuppression:
She has been immunosuppressed on various different medications.
Her current regimen is Cellcept 1500 mg orally twice a day , Neoral 125
mg orally twice a day , prednisone 25 mg orally twice a day For prophylaxis ,
she is also on Valcyte 450 mg orally daily , and Bactrim one double
strength tab every other day as well as nystatin swish and swallow and
powders for her axilla and groin. She has not spiked any temps
and none of her cultures have been positive except for one
urinary culture positive for Gram-negative rods for which she is
on levofloxacin 250 daily for seven days.
Endocrine: Her sugars have been very difficult control. She was
initially on the Portland protocol for several days
postoperatively and on an insulin drip according to her sugar
levels. Diabetes Management Service was consulted and has been
assessing her daily for her insulin needs. She is currently on a
regimen that consist of 30 mg of Lantus every evening as well as
8 units of Novolog with every meal and sliding scale coverage
with Novolog for meals as well. Her sugars are mildly well
controlled but could use tighter glycemic control.
Tubes , Lines , and Drains:
Her wires and chest tubes have been removed. She has no central
access. She just has peripherals.
MEDICATIONS AT THE TIME OF TRANSFER:
Diltiazem 15 mg orally every 8 hours , folic acid 1 mg orally daily , Ativan 1
mg orally every 8 hours and 1 mg orally every 6 hours as needed agitation , magnesium
sliding scale orally twice a day , magnesium sulfate sliding scale intravenous
daily , Niferex 150 mg orally every 12 hours , nystatin 5 ml orally four times a day ,
prednisone 25 mg orally twice a day , MVI therapeutic with minerals ,
thiamine hydrochloride 100 mg orally daily , prednisone 25 mg orally
twice a day , thiamine 100 mg orally daily , milrinone intravenous 0.2
mcg/kg/minute , Neoral 125 mg orally twice a day , Bactrim DS one tablet
orally daily , Cellcept 1500 mg orally twice a day , levoflox 250 mg orally
daily x7 doses , miconazole 2% powder TP every 8 hours , and Celexa 20 mg
orally daily , Nexium 40 mg orally daily , Valcyte 450 mg orally daily ,
Lantus 30 units subcutaneous every bedtime , DuoNeb every 6 hours , Novolog 4
units subcutaneous before every meal , Novolog sliding scale subcutaneous
before every meal , Novolog sliding scale subcutaneously every bedtime , Novolog 8 units
subcutaneous before every meal
DISPOSITION:
She is being transferred to the step-down unit in stable
condition.
eScription document: 8-6359606 EMS
Dictated By: REPLENSKI , DEBERA ZADA
Attending: COLASAMTE , ISABELLE EVON
Dictation ID 6445393
D: 3/18/05
T: 3/18/05

Document id: 8

098812026 | PUO | 57870793 | | 8056405 | 10/6/2003 12:00:00 a.m. | CHF exacerbation | | DIS | Admission Date: 7/14/2003 Report Status:

Discharge Date: 5/6/2003
****** DISCHARGE ORDERS ******
BENKERT , DARREN L 301-57-85-5
Walk
Service: MED
DISCHARGE PATIENT ON: 5/17/03 AT 09:00 a.m.
CONTINGENT UPON SNF/rehab
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DANIEL , CORAZON MERTIE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed sob
OSCAL ( CALCIUM CARBONATE ( 500 MG ELEM. CA++ ) )
500 MG orally three times a day
LASIX ( FUROSEMIDE ) 80 MG orally twice a day
HCTZ ( HYDROCHLOROTHIAZIDE ) 25 MG orally every day
ATROVENT INHALER ( IPRATROPIUM INHALER ) 2 PUFF inhaled four times a day
as needed sob
LISINOPRIL 60 MG orally every day HOLD IF: SBP<100
Alert overridden: Override added on 6/10/03 by
DIMITROV , YOLONDA ZULA , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: aware
LOPRESSOR ( METOPROLOL TARTRATE ) 50 MG orally three times a day
HOLD IF: sbp<100 , heart rate<55 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
AMLODIPINE 10 MG orally every day HOLD IF: SBP<100
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DETROL ( TOLTERODINE ) 2 MG orally twice a day
Number of Doses Required ( approximate ): 10
DIET: Patient should measure weight daily
DIET: Fluid restriction: 2 liters
DIET: 4 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Meghann Christenson May scheduled ,
ALLERGY: Aspirin , Iron ( ferrous sulfate ) , Nsaid's
ADMIT DIAGNOSIS:
CHF exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
obesity ( obesity ) restrictive lung disease ( restrictive pulmonary
disease ) chf ( congestive heart failure ) fibromyalgia
( fibromyalgia ) von willebrand's ( hemophilia ) sleep apnea ( sleep
apnea ) iron deficiency anemia ( iron deficiency anemia ) hypoxia
( hypoxia ) GERD , history of TAH/BSO , PICA. ? central hypoventilation syndrome.
OA.
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
45 year-old female with multiple medical problems including pulmonary
hypertension , obstructive sleep apnea , diastolic CHF ( EF 60% ) admitted
initially for elective hemmorhoidectomy but flunked pre-op cardiology
eval and was transfered to medicine in decompensated CHF for diureses.
patient recently hospitalized 7/19/06 for chf exacerbation ( diastolic
dysfunction ) 2nd to dietary and medicine noncompliance ( salty foods ,
stopped her HCTZ ) and continued to smoke. patient diuresed and sent home
on new lasix 60qam 40qpm regimen. patient noticed steady decline in
functional status during the last 3 weeks because of SOB. at baseline
should sat 85% on ra , 95% on 6L02NC at rest and ambulation. ( on home
o2 ) but now , can't ambulate , sating 83-89% on 6l at rest. patient confessed
to not adhering to lasix regimen , still eating pizza and salty foods.
also notes pnd , orthopnea. patient notes intermittent chest pain on and off
lasting 5 minutes not associated with exertion or any other cardiac
sx. 8/15 dobuta mibi-> ischemia in d1 territory. 11/19 :echo->ef 60% ,
Pa pressure 48 + RA. no valve dz. rv enlarged and hypokinetic. A/P:
pump: decompesated CHF ( diastolic dysfxn , ? cor pulmonale component )
2nd to diet/med non-compliance. uptitrate captopril , continue intravenous lasix
60 every day with goal net neg 2 liters , daily weights , strict Iand O. check
cxray. Switched to orally lasix 10/06 , back to lisinopril for d/c Fri.
ischemia: has + mibi in past , but no further workup to d1 lesion. can't
get ecasa 2nd to vWD. continue BB , will hold off on statin since not
hyperlipidemic. rate:tele. rheum:fibromyalgia ( in arms and should )
urology:detrol for urinary incont. psych: depression/?personality
disorder. obgyn: will hold off on premarin given cardiac status.
surgery:post pone hemmerhoidectomy , not needed with stable crit. fen:
twice a day lytes 2gm Na 2000cc water restriction code status full , until can
speak with fiancee. pulm: BIPAP at night. heme: has vonwillebrands
disease and ecasa is a contraindication. if patient needs to go to surgery
will need pre-op and post-op humate-P ( per dr. harajly
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
VNA instructions:
1 ) Please measure patient's weight daly if scale available , can doctor if
her weight goes up by >4 lbs in 48hrs.
2 ) Please assess patient's ability to tolerate BIPAP.
3 ) Home safety evaluation , patient's ability to peform ALDs.
4 ) Please assess med compliance , compliance with no added salt/2L fluid
restriction.
No dictated summary
ENTERED BY: DIMITROV , YOLONDA ZULA , M.D. , PH.D. ( VO0 ) 5/17/03 @ 07:08 a.m.
****** END OF DISCHARGE ORDERS ******

Document id: 9

279704264 | PUO | 05648655 | | 3536057 | 12/10/2005 12:00:00 a.m. | history of ICD placement | | DIS | Admission Date: 12/10/2005 Report Status:

Discharge Date: 11/5/2005
****** FINAL DISCHARGE ORDERS ******
PERKO , TRUMAN 294-06-75-6
Bentry Boulevard , Nida
Service: CAR
DISCHARGE PATIENT ON: 6/20/05 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GRINSTEAD , JACKLYN A. , M.D. , M.S.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ALBUTEROL INHALER 2 PUFF inhaled four times a day
as needed Shortness of Breath , Wheezing
LASIX ( FUROSEMIDE ) 20 MG orally every day Starting Today ( 5/29 )
Instructions: please titrate your dose 20mg/40mg/60mg as
you normally do depending on your degree of swelling
MOTRIN ( IBUPROFEN ) 600 MG orally every 6 hours as needed Pain , Headache
Food/Drug Interaction Instruction Take with food
Alert overridden: Override added on 6/12/05 by BLACKGOAT , GERMAINE L KATE MICHALE , M.D.
on order for MOTRIN orally ( ref # 976338446 )
patient has a POSSIBLE allergy to Aspirin; reaction is Unknown.
Reason for override: patient tolerates motrin
ATROVENT HFA INHALER ( IPRATROPIUM INHALER )
2 PUFF inhaled four times a day
MAGNESIUM OXIDE 560 MG orally every day
VERAPAMIL SUSTAINED RELEASE 120 MG orally every day
Starting Today ( 5/29 )
Instructions: please confirm home dose and resume home dose
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
KEFLEX ( CEPHALEXIN ) 250 MG orally four times a day X 10 doses
Instructions: started on 5/29 , continue through 5/3 for
12 total doses Number of Doses Required ( approximate ): 20
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
AMBIEN ( ZOLPIDEM TARTRATE ) 10 MG orally every bedtime as needed Insomnia
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LORATADINE 10 MG orally every day Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Give on an empty stomach ( give 1hr before or 2hr after
food )
POTASSIUM CHLORIDE SLOW REL. ( KCL SLOW RELEASE )
20 MEQ orally every day As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
METFORMIN 1 , 250 MG orally twice a day Starting IN a.m. ( 5/29 )
RHINOCORT AQUA ( BUDESONIDE NASAL INHALER )
2 SPRAY inhaled twice a day
SINGULAIR ( MONTELUKAST ) 10 MG orally every day
EFFEXOR XR ( VENLAFAXINE EXTENDED RELEASE ) 75 MG orally every day
Number of Doses Required ( approximate ): 5
ADVAIR DISKUS 250/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally every day
OXYCODONE 10 MG orally every 4 hours as needed Pain
DIET: Patient should measure weight daily
DIET: Fluid restriction
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Jacklyn Grinstead 10/20/06 1:30pm scheduled ,
Dr. Sachiko Borriello 1/11/06 2:45pm scheduled ,
ALLERGY: broccoli , Aspirin
ADMIT DIAGNOSIS:
ICD placement for HCM
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
history of ICD placement
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
see below
OPERATIONS AND PROCEDURES:
10/14/05: Metronic dual chamber DDI/ICD paced under general anesthesia
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
REASON FOR ADMIT: ICD placement
HPI: 53yoF with HCM history of medtronic dual chamber DDI/ICD placement under
general anesthesia ( 2/2 obesity ) admitted for ovenight observation. ICD
placed for primary prevention. Had ECHO 6/29 showed septal thickness
16mm , posterior wall thickness 19mm with preserved EF 65%m LV outflow tract
peak gradient 125mmHg. Holter monitoring 11/21 without any arrythmias
but since 8 of July has had increasing difficulties with ambulatio n2/2
palpations up to 20 minutes at a time. One severe presyncopal episode in
August of 2004. Also HF symptoms controlled on lasix , at baseline can work
6 blocks and up one flight of stairs.
*****************
PMH: HCM , htn , hyperchol , asthma , PCOD with infertility , diabetes ,
obesity ( 310 lbs ) , loer back pain , migraines , history of knee replacement ,
tosillectomy , sinus surgery
******************
Admission Meds: albuterol , advair 250/50 twice a day , rhinocort 2 sprays twice a day ,
atrovent 2 puff four times a day , singulair 10mg every bedtime , nexium 40mg daily , lasix
20mg daily ( inc to 40 or 60 during period ) , kcl 20meq
daily , verapamil 120mg daily , patanol 1-2 each eye twice a day as needed , loratidine 10mg
daily , zocor 20mg every bedtime , effexor 75mg daily , metformin 1250mg twice a day ,
mgoxide 500mg daily , ambien as needed , amox prior to procedures
******************
all: aspirin , broccoli , tape
******************
FH: no history of HOCM. no history of sudden cardiac death. mother/grandmother with
diabetes
SH: technical writer lives in Aford Terbberkeprai Bo single parent of twins. no
tob/social etoh/ivdu.
******************
ADMISSION PE: VS 96.4 74 140/90 20 93% RA
GEN: NAD HEENT: anicteric , eomi , perrl , mmm , op clear NECK: carotid 2+
without bruits , no lan , jvp difficult to appreciate 2/2 thick neck LUNGS:
ctab , no c/with r CV: rr , nl s1 s2 , 3/6 SM at RUSB but heard throughout
precordium , inc with valsalva ABD: obese , nl bs , soft , nt/nd , hard to
palpate for masses and hsm EXT: trace edema , warm , dp/patient 2+ b/l. left
radial pulse 2+ SKIN: no rashes NEURO: a&ox3 cn 2-12 intact , moves all
extremities
*************************
LABS/STUDIES
--labs: cbc , bmp , coags wnl
--EKG NSR. TW flat V5/V6 ( old )
--CXR ( portable ): cardiomegaly , no e/o ptx. PA/lat CXR a.m. after no ptx ,
leads in place , no overt failure.
*************************
PROCEDURES:
6/14 history of Medtronic ICD/DDI PPM placement , cannulated via left cephalic
( one axillary attempt )
*************************
A/P
CV:
--pump: HOCM. Euvolemic initially on exam. O/n patient developed increased
swelling of her hands and legs b/l , and also with slightly more SOB and O2
requirement. Unclear whether O2 requirement was 2/2 fluid or 2/2 OSA , a.m.
CXR clear with out e/o overload. patient diuresed with lasix 40mg on day of d/c
about net -500cc. Still with some swelling on d/c but patient reported that her
breathing/activity level was at baseline and she felt comfortable going
home and adjusting her lasix dose as she normally does based on her
swelling. Continued on home cardiac regimen verapamil and zocor.
--rhythm: history of Medtronic dual chamber DDI/ICD placement for primary
prevention for HOCM. Post procedure CXR with out ptx , leads in place. patient will
f/u with Dr. Grinstead . On monitor patient sinus with out events. Routine
peri-procedure antibiotics.
PULM: asthma , cont home regimen. had slight desat o/n requiring 2L O2
which could be 2/2 overload ( see above ) , but also could be 2/2 obstructive
sleep apnea , consider outpt eval for this.
GI: cont ppi
ENDO: ISS. restarted metformin on morning of d/c.
NEURO: cont effexor
FEN: cardiac diet
PPx: teds
CODE: has icd now. full
ADDITIONAL COMMENTS: *Please monitor your weight and swelling and adjust Lasix dose as your
normally do. Please call Dr. Borriello if your swelling does not improve
or you become short of breath or your weight increases >3pounds.
*Take Keflex for 3 day total course. All other medications are the same.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
*fluid management
*consider outpt eval for possible obstructive sleep apnea
No dictated summary
ENTERED BY: BLACKGOAT , GERMAINE LAVONNE KATE , M.D. ( ZE37 ) 6/20/05 @ 02:11 PM
****** END OF DISCHARGE ORDERS ******

Document id: 10

172100234 | PUO | 34013384 | | 881982 | 7/16/1993 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/3/1993 Report Status: Signed

Discharge Date: 3/4/1993
DISCHARGE DIAGNOSIS: ATYPICAL CHEST PAIN.
ASSOCIATED DIAGNOSES: 1. HYPERTENSION.
2. HISTORY OF CORONARY ARTERY DISEASE.
3. SCIATICA.
HISTORY OF PRESENT ILLNESS: The patient is a 46 year old woman
with a history of coronary artery
disease , hypertension and chronic pain , admitted with chest pain.
Her cardiac risk factors are hypertension , increased cholesterol ,
positive family history and history of coronary artery disease. She
has a history of Q wave myocardial infarction with right
ventricular infarct in October 1992. Peak CK's were 2300.
Catheterization showed 100% RCA lesion which was treated with
angioplasty reduced to 20-30% stenosis. The patient had chest pain
the succeeding months and had two catheterizations showing no
change in her coronary arteries. Echocardiogram showed an LVEF of
50%. Subsequent catheterization October 92 , July 92 and September 92
for atypical chest pain , showed clean coronaries. Exercise tread
mill test in September 92 , the patient went three minutes and 31 seconds
with standard Bruce protocol and stopped secondary to atypical
chest pain. Maximum heart rate 162 , blood pressure 176/90 , no ST
or T wave changes. In April 92 she ruled out for myocardial
infarction by enzymes and EKG , after presenting with prolonged
chest pain. VQ scan was low probability. Chest CT ruled out aortic
dissection. The patient was referred to the Pain Service. In
February 1993 the patient had additional sharp chest pain , again
ruled out for myocardial infarction , was seen by the Pain Services
and discharged on trazodone and Relafen plus cardiac medicines.
The patient now presents to the hospital with 24 hours of right
sided chest pain , stating that it was squeezing in her right
breast , felt to be between the shoulder blades. She took two
sublingual Nitroglycerin the day before admission and three on the
morning of admission without relief. She complained of shortness of
breath , dizziness , weakness and nausea , no palpitations were noted.
The pain was not worse with positional changes. The patient is seen
in the Stusri Medical Center emergency room where she received
two sublingual Nitroglycerins which reduced her pain from 7/10 to
1/10 level. She also received 10 mg intravenous Morphine , 725 mg intravenous
Lopressor , two inches Nitro Paste and two liters of oxygen. The
pain was intermittent through the rest of the day. She had no
fever , chills , cough , she did complain of urinary frequency ,
chronic left back pain and right lower extremity pain. ALLERGIES:
Penicillin , erythromycin and tetracycline which causes hives.
PHYSICAL EXAMINATION: Pulse 92 , blood pressure 148/100 ,
temperature 98.1 , she is an obese female in
no acute distress. Cardiac , regular rate and rhythm , SI , SII , no
murmurs , rubs or gallops. The pain is not reproducible by
palpation. Extremities , 1+ edema of the lower extremities with
preserved peripheral pulses.
LABORATORY DATA: Cholesterol 226. EKG showed normal sinus rhythm
of 90 beats per minute , normal intervals , left
ventricular hypertrophy. There were T wave inversions in Leads I ,
V2 , V6 , bisphasic T waves V5 , flat waves V3 , V4 , left atrial
enlargement. Compared with the examination of 2/7/93 T wave
inversions were less deep in V3 through V5.
HOSPITAL COURSE: The patient ruled out for myocardial infarction by
serial EKG and enzymes. Her blood pressure was
initially poorly controlled and she was placed on a regimen of
Aldomet 750 mg orally twice a day; Lopressor 150 mg orally three times a day;
Nifedipine XL 120 mg orally twice a day On 11/28/93 the patient underwent
cardiac catheterization which showed normal coronary arteries ,
mildly elevated pulmonary pressure of 40/24 and mean of 30 ,
capillary wedge pressure of 14 mm mercury. On the afternoon of
5/10 the patient had 600 mg of Levatol and two hours later
complained of light-headedness with a systolic blood pressure in
the 80's. This gradually increased to greater than 110 systolic so
the patient was placed in Trendelenburg position and received 400
cc's of intravenous fluids. She was also noted to have the onset of
wheezing. 02 sat was 95% on five liters of oxygen , chest x-ray
showed cardiac enlargement with regeneration of the pulmonary flow
suggestive of mild congestive heart failure. The patient received
albuterol nebs every 15 minutes x 4 with good response and was felt to
have had a bronchospastic reaction to beta blockers. She did well
for the rest of her hospitalization , had no further chest pain.
DISPOSITION: She was discharged in good condition to home with
instructions to followup with Dr. Weight on Tuesday
May .  MEDICATIONS: Enteric coated aspirin 1 orally every day;
Pepcid 20 mg orally twice a day; trazodone 100 mg orally every bedtime; Elavil 25
mg orally every bedtime; Procardia XL 90 mg orally twice a day; Lopressor 100 mg
orally three times a day
Dictated By: LEOLA MUSICH , M.D. GQ35
Attending: YOSHIE S. POSPISHIL , M.D. PD97  AT320/0730
Batch: 5846 Index No. YLBBV91WBO D: 10/10/93
T: 3/10/93

Document id: 11

580084969 | PUO | 29047049 | | 1348217 | 8/20/2003 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: Report Status: Signed

Discharge Date: 6/21/2003
Date of Discharge: 6/21/2003
ATTENDING: RUFUS CARLIE BERNAS MD
ADMITTING DIAGNOSIS: Shortness of breath.
DISCHARGE DIAGNOSES:
1. Pulmonary fibrosis.
2. Pulmonary hypertension.
3. Diverticulitis.
4. Acute renal failure.
5. Gout.
6. Hypertension.
7. High cholesterol.
8. Diabetes Mellitus.
BRIEF HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old
female with a past medical history of significant obesity ,
diabetes , hypertension , hypercholesterolemia , heart failure ,
pulmonary fibrosis , on home O2 who presented with shortness of
breath , and left jaw pain on 8/10/2003 .  She had been in her
usual state of health until approximately 6 p.m. on the day of
admission , when at that time , she suddenly became short of
breath. She reports that she then sat down in her wheelchair and
"passed out." However , it is unclear if the patient actually
lost consciousness. The patient also developed jaw pain
radiating to her back while EMTs were present and also complained
of a tug in her chest. The pain was unrelieved by nitroglycerin ,
oxygen; it was constant in nature. At the time of her arrival in
the emergency room , the patient was hemodynamically stable with
an O2 sat of 99% on room air. She was given sublingual nitrate
with no effect. Because of her history of coronary artery
disease , she was tried on heparin and aspirin.
PAST MEDICAL HISTORY:
1. Pulmonary fibrosis , on home O2.
2. Reported history of an anterolateral MI.
3. Diabetes.
4. Hypertension.
5. High cholesterol.
MEDICATIONS: On admission , insulin 70/30 22 units every day before noon 26
units every afternoon , atenolol 25 every day , Zocor 20 every day , Zoloft 50 every day ,
Lasix 60 orally twice a day , Neurontin 100 three times a day , aspirin , and
multivitamin.
ALLERGIES: Penicillin.
PHYSICAL EXAMINATION: On admission , temperature was 97 , pulse
was 54-60 , blood pressure was 100-120/50-80 , and O2 sat was 98%
to 99% on 6 liters. She was a moderately obese woman in no acute
distress. Her lung are notable for crackles at the bases. Her
cardiac exam was notable for distant heart sounds with a normal
S1 , S2. She had no pedal edema in her extremities.
LABORATORY DATA: On admission were notable for a BUN and
creatinine of 31 and 1.1. Normal LFTs The patient's hematocrit
was 38. Her D-dimer was 736.
Her EKG showed normal sinus at low voltages , poor R-wave
progression.
IMPRESSION: At the time of admission , the patient was a
62-year-old female with morbid obesity and chronic episodes of
shortness of breath , this time accompanied by jaw pain and with a
history of coronary artery disease and multiple risk factors
concerning for acute coronary syndrome. The patient was
initially treated for a possible ischemic event. Diagnosis of PE
results were considered. However , the patient was not
tachycardic. She did not have any chest pain or new O2
requirements and had had several workups for pulmonary embolism
during prior hospitalization with similar systems , so therefore ,
this was thought to be less likely.
HOSPITAL COURSE: By system:
CARDIAC. In terms of ischemia , the patient had 3 tests of
cardiac enzymes , which returned negative. She was maintained on
telemetry , and she had EKG checked , which did not reveal any
changes. This was a patient who had a dobutamine MIBI , which was
negative for any evidence of ischemic changes. During the MIBI ,
there was no evidence of ischemia and/or scar. The patient was
continued on her outpatient medications including aspirin , Zocor ,
and atenolol. However , at a later point in her hospitalization ,
she became hypotensive at which time her atenolol was temporarily
DC'd , but this was restarted prior to discharge. In terms of the
patient's cardiac function , she has a history of CHF and is on
Lasix as an outpatient. An echocardiogram was repeated during
this hospitalization , which was notable for an EF of 60% ,
trace-to-mild MR , moderate TR , and estimated pulmonary systolic
pressure at 70 mmHg. The patient was continued on outpatient
Lasix regimen until at a later point during this hospitalization ,
the patient became hypertensive with acute renal failure at which
time her Lasix was discontinued. Lasix was restarted prior to
discharge. In terms of the patient's rhythm , she had no evidence
of arrhythmias monitored throughout her hospitalization.
GI. On 10/10/2003 , the patient developed acute onset of diarrhea
and lower abdominal pain. Now , this pain was nonradiating ,
alternating sharp and dull but constant , associated with nausea
and vomiting , and frequent stools. At times , the stools were
notable for bright red blood. The patient was therefore started
on levofloxacin and Flagyl as treatment for diverticulitis versus
ischemic colitis. To further evaluate this , a CT scan of the
abdomen was done , which was notable for a thickened colon for 10
cm at the hepatic flexure. Given this information , it was the GI
consult's opinion that this is most likely consistent with
diverticulitis , and the plan was to treat it aggressively with
antibiotics , and once the symptoms resolved , recommended a
colonoscopy several weeks after discharge. The patient was
continued on levofloxacin and Flagyl , but then , several days
later , became hypotensive with systolic blood pressures in the
80s. At this time , the patient's antibiotic coverage was changed
to include Ceptaz and vancomycin , and she also received 1 dose of
gentamicin. By the time of discharge , the patient's abdominal
symptoms have completely resolved. She is no longer having any
abdominal pain , and she needs no longer having any diarrhea and
is tolerating a regular diet without any difficulties. The plan
is for her to have a followup colonoscopy as an outpatient.
PULMONARY: The patient was admitted for shortness of breath. A
differential diagnosis at that time included chronic pulmonary
embolism versus cardiac etiology versus deconditioning in the
setting of a chronic pulmonary fibrosis. To establish that the
patient did not have any PE , she had lower extremity Doppler
exams , which were negative. She also had a physical therapy protocol CT , which
was negative for any evidence of clots. Because the patient does
have cardiopulmonary hypertension , she was started on Coumadin as
prophylaxis for any thrombosis in the setting of her low flow in
her pulmonary vasculature. Throughout this hospitalization , she
was continued on her own home regimen of O2.
RENAL: The patient has baseline chronic renal insufficiency with
a baseline creatinine at 1.4 during this hospitalization at a
time that her diarrhea was very severe , and when her blood
pressures fell in the 80s , the patient developed acute renal
failure with a peak creatinine of 2.4 with decreased urine
output. The thought of the team was that this represented a
renal failure in the setting of her diarrhea , fluid losses , and
hypertension. Her pheno was consistent with this at 0.71. She
was treated with aggressive intravenous fluids. She also had a renal
ultrasound , which was normal. She did have 1 day of hematuria ,
which was thought to be due most likely to Foley trauma , which
resolved at the time of discharge.
ID: The patient's hospital course was notable for a diarrhea as
mentioned in GI. She was initially treated with levofloxacin and
Flagyl and then when she became hypertensive was then change her
Flagyl , Ceptaz , and vancomycin with 1 dose of gentamicin. Her
symptoms dramatically improved on these antibiotics on 9/18 she
was changed from intravenous antibiotics to a orally regimen of Flagyl and
levofloxacin. The plan is for her to continue a total of 14 days
of antibiotics. I anticipate the last day of antibiotic coverage
will be 2/19/2003 .
RHEUMATOLOGY: On 10/27/2003 , the patient was noted to have left
knee pain and was noted to have some focal lateral patellar
tenderness and swelling. A knee aspirate was performed and urate
crystals were identified , and the patient was diagnosed with
gout. Because of her chronic renal insufficiency and diarrhea ,
the decision was made to treat her gout flare with steroids , and
she is currently is on a steroid taper as treatment.
ENDOCRINE: The patient has a history of diabetes. She takes
70/30 insulin at home. She was initially continued on an
outpatient regimen; however , when she started to begin having
massive diarrhea , she was taken off her long-acting insulin ,
because she was not taking anything by orally At this time , she
was not tolerating a regular diet , and her insulin requirements
were increasing. It is recommended that as an outpatient , she
resumes one-half of her regular outpatient insulin dose for 1 or
2 days to ensure that her insulin requirements in her diet are
appropriate , and then , she should resume her regular insulin
dosage.
DISCHARGE MEDICATIONS: Include aspirin 325 mg orally every day ,
atenolol 25 mg orally every day , Lasix 60 mg orally twice a day , Zoloft 50 mg
orally every day , Zocor 20 mg orally every bedtime , Neurontin 300 mg orally twice a day ,
levofloxacin 500 mg orally every day , Coumadin 2.5 mg orally every day ,
prednisone taper - which involves 10 mg of prednisone on 8/14
followed by 5 mg of prednisone on 10/27 , 1/24 , and 3/1 and
then stop , Flagyl 500 mg orally three times a day , insulin 70/30 11 units
every day before noon 13 units every afternoon - once it is established that the patient
has returned to her regular diet , this dosage should be doubled
to her outpatient regular dose , and Flexeril 10 mg orally three times a day
DISPOSITION: The patient has been discharged to a rehab
facility.
FOLLOWUP: The patient is to follow up with her primary care
physician , Dr. Macisaac following discharge.
ADDITIONAL INSTRUCTIONS: Antibiotics should be continued until
2/19/2003 .  The patient should have her INR checked in 3 days.
Her goal INR is 2. Once off levofloxacin , her dose of Coumadin
may need to be adjusted.
2. The patient should have an outpatient colonoscopy and treated
for a week to further assess for diverticulitis.
3. Fingerstick blood glucoses should be followed regularly as
the patient's insulin dose is titrated up to her previous
outpatient dose.
eScription document: 3-7746634 KFFocus
Dictated By: HALFACRE , SOLOMON LIESELOTTE
Attending: BERNAS , RUFUS CARLIE
Dictation ID 7393365
D: 1/1/03
T: 1/1/03

Document id: 12

969667536 | PUO | 96328556 | | 1009957 | 11/10/2006 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 11/10/2006 Report Status: Signed

Discharge Date: 2/19/2006
ATTENDING: MANKOSKI , ROSSIE MD
HISTORY OF PRESENT ILLNESS: Mr. Baldon is a 52-year-old gentleman
who was initially admitted to Osri Medical Center due to nausea ,
myalgias and weakness. The patient has a history of type I
diabetes mellitus , end-stage renal disease with
subsequent renal transplant 11 years ago donated by his sister
for which he takes cyclosporine and azathioprine. The patient
had a neuropathic left plantar ulcer seven years ago for which he
underwent transmetatarsal amputation of his left foot at Osri Medical Center .
He has had a chronic recurrent ulcer of the left foot
over the last two years or so. The patient nonetheless was
reasonably doing well and very active. He recently did a 35-mile
bike ride in about four or five days prior to admission. He
developed nausea and vomiting which lasted for one day. He then
developed weakness and hyperglycemia. He tried to increase his
insulin , but found he did not have an adequate response. The
patient became more weak and was brought to the Osri Medical Center Emergency Department where he was found to have moderate
diabetic ketoacidosis and dehydration. The patient's workup also
suggested acute myocardial infarction and was admitted to the
Coronary Care Unit. Echocardiogram was performed which revealed
an ejection fraction of 30% with dyskinesis of the inferior and
apical walls , mild mitral insufficiency , mild tricuspid
insufficiency. Transesophageal echocardiogram revealed mild left
atrial enlargement and intact interatrial septum , mild mitral
regurgitation , left atrium with history of thrombus ,
inferobasilar and inferoseptal akinesis consistent with old
inferoposterior myocardial infarction , mild tricuspid
regurgitation , trileaflet aortic valve , which is quite mobile
with no evidence for significant aortic insufficiency , normal
pulmonic valve and aortic atherosclerosis. No pericardial
effusion and no evidence of endocarditis. The patient developed
a fever the day of admission and blood cultures were drawn which
grew out Streptococcus morbillorum and Bacteroides. His foot
became clearly boggy and grossly infected with necrosis.
Within an hour of that he underwent guillotine amputation of his
left foot. His temperature normalized and his foot cultures grew
out Streptococcus mutans and E. coli as well as Bacteroides
fragilis. He received ampicillin and sulbactam for bacteremia on
11/2/06 .  He underwent a coronary cardiac catheterization and
was found to have the following , left main coronary artery with
an ostial 100% stenosis. Formal report is not available at this
time. The patient was then transferred to Pagham University Of for coronary artery bypass grafting.
PAST MEDICAL HISTORY: Significant for myocardial infarction ,
history of class II heart failure , hypertension , peripheral
vascular disease , diabetic vasculopathy , renal failure and
nephropathy.
PAST SURGICAL HISTORY: Significant for left transmetatarsal
amputation , recent left guillotine amputation of left foot and
renal transplant 11 years ago.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON TRANSFER , Lopressor 25 mg twice a day , lisinopril 40 mg
daily , aspirin 325 mg daily , cyclosporine 50 mg twice a day ,
azathioprine 125 mg daily , NPH insulin 74 units in the morning
and 72 units in the evening.
PHYSICAL EXAMINATION: A 6 feet 2 inches tall , 113.63 kilograms ,
temperature 98.6 , heart rate 79 and regular , blood pressure right
arm 130/65 , left arm 137/68 , oxygen saturation 97% on room air.
Cardiovascular , regular rate and rhythm with a 2/6 holosystolic
murmur. Peripheral vascular 2+ pulses bilaterally. Carotid ,
radial and femoral pulses , nonpalpable left dorsalis pedis and
posterior tibialis pulses and dopplerable right dorsalis pedis
and posterior tibialis pulses. Neurologic , alert and oriented
with no focal deficits.
ADMISSION LABS: Sodium 135 , potassium 3.6 , chloride of 101 , CO2
27 , BUN of 10 , creatinine 0.8 , glucose 113 , magnesium 1.9 , WBC
10.6 , hematocrit 29.9 , hemoglobin 10 , platelets of 501 , and
physical therapy-INR 1.1.
HOSPITAL COURSE: Mr. Baldon was brought to the operating room on
2/1/06 where he underwent an urgent coronary artery bypass
graft x4 with a sequential graft from the saphenous vein graft
from aorta to the ramus and then the second obtuse marginal
coronary artery and left internal mammary artery to left anterior
descending coronary artery and a saphenous vein graft to the
posterior descending coronary artery. Total bypass time was 121
minutes. Total crossclamp time was 104 minutes. The patient did
well intraoperatively , came off bypass without incident and was
brought to the Intensive Care Unit in normal sinus rhythm and in
stable condition. Postoperatively , the patient did well. He was
extubated and transferred to the Step-Down Unit on postoperative
day #1. Infectious Disease Service was called and recommended
treating the patient with levofloxacin and Flagyl for total of 14
days for his left leg BKA site. The patient's chest tubes were
removed and post-pull chest x-ray revealed no pneumothorax.
Dr. Stacie Halechko from the Vascular Surgery Service was consulted and
the patient was scheduled for revision of his left BKA on
11/9/06 .  Mr. Baldon was also followed by the Diabetes Mellitus
Service postoperatively for his insulin regimen. He also
experienced some postoperative urinary retention with several
failed voiding trials. The patient will be discharged with a leg
bag and will follow up with a urologist within five to seven days who will be
assigned by his primary care physician. The
patient had already been started on Flomax 0.4 mg daily. The
patient also worked with physical therapy and is able to pivot
with assist and will be discharged to home with physical therapy. Mr. Baldon was
cleared for discharge to home with visiting nurse and physical therapy on postoperative day
#11. Mr. Baldon also had postoperative anemia and was transfused with one unit of
packed red blood cells for a hematocrit of 22 with a repeat at time
of discharge to 23.4. He also required further diuresis and
appears to be hemodiluted. The patient was also instructed on
sternal precautions due to his left BKA and patient and the
family were shown sternal precautions.
DISCHARGE LABS: Sodium 134 , potassium 4.6 , chloride of 100 , CO2
27 , BUN of 15 , creatinine 0.8 , glucose 136 , magnesium 1.6 , WBC
8.30 , hematocrit 23.4 , hemoglobin 7.5 , platelets of 471 , physical therapy 16.7 ,
physical therapy/INR of 1.3 , and a PTT of 37.1.
DISCHARGE MEDICATIONS: Vitamin C 500 mg twice a day , Lipitor 20 mg
daily , azathioprine 125 mg daily , cyclosporine ( Sandimmune ) 50 mg
twice a day , enteric-coated aspirin 325 mg daily , Lasix 40 mg daily
for five doses along with potassium chloride slow release 20 mEq
daily for five doses , Neurontin 300 mg three times a day subcutaneously ,
heparin 5000 units subcutaneously every 8 hours , Dilaudid 4-6 mg every 4 hours
as needed pain , NovoLog 20 units before every meal , Lantus 100 units every 8 p.m. ,
levofloxacin 500 mg daily for two remaining doses , Toprol-XL 100
mg daily , Niferex 150 mg twice a day and Flomax 0.4 mg daily.
Mr. Baldon will follow up with Dr. Rossie Mankoski in six weeks
and his cardiologist Dr. Marcela Jone in one week and an
urologist to be signed by his primary care physician within five
to seven days and also Dr. Stacie Halechko the vascular surgeon in
two to three weeks. He is otherwise clear for discharge to home
with visiting nurse. The patient has also been instructed to
keep his left leg immobilizer brace on until follow up with Dr.
Halechko in two to three weeks.
eScription document: 1-2467341 CSSten Tel
Dictated By: BARBELLA , PRISCILLA
Attending: MANKOSKI , ROSSIE
Dictation ID 3035580
D: 7/15/06
T: 11/6/06

Document id: 13

628567699 | PUO | 85842554 | | 8535988 | 5/26/2007 12:00:00 a.m. | ATRIAL FIBRILLATION , ?ENDOCARDITIS | Signed | DIS | Admission Date: 2/21/2007 Report Status: Signed

Discharge Date: 9/29/2007
ATTENDING: FANIEL , GAYLENE M.D.
SERVICE: Nessopor Gilb Hagund Health Center .
PRINCIPAL DIAGNOSIS: Bacteremia , endocarditis.
OTHER PROBLEMS AND DIAGNOSES:
1. Status post aortic valve repair.
2. Hypertension.
3. Hyperlipidemia.
4. Coronary artery disease status post CABG.
5. CHF.
6. Anemia.
7. Status post hemorrhagic stroke.
8. BPH status post pubic catheter placement.
BRIEF HISTORY OF PRESENT ILLNESS: This is an 82-year-old male
with history of multiple medical problems including recent aortic
valve replacement for aortic stenosis on 4/2 , CAD status
post CABG , CHF , atrial fibrillation with slow ventricular
response , insulin-dependent diabetes who presents from rehab with
positive blood cultures. The patient had been in rehabilitation
following a Totin Hospital And Clinic admission when he spiked a
temperature two days prior to admission and was found to have
blood cultures growing out gram positive cocci. He was also
found to have a positive urinalysis at rehab. The patient was
treated with two doses of ciprofloxacin for positive UA and
admitted to Petersram Medical Center for positive blood cultures and concern
for endocarditis given his recent aortic valve repair.
On review of systems , the patient denies chest pain , shortness of
breath , cough , URI symptoms , rash , nausea , vomiting , diarrhea ,
abdominal pain , dysuria , palpitations , fevers , sweats or chills
and overall reports feeling well.
PAST MEDICAL HISTORY:
1. Status post aortic valve replacement in 4/10 .
2. Hypertension.
3. Hyperlipidemia.
4. CAD status post CABG.
5. CHF.
6. Atrial fibrillation with slow ventricular response.
7. Insulin dependent diabetes mellitus.
8. Anemia.
9. Status post hemorrhagic stroke.
10. BPH status post suprapubic catheter placement during AVR
surgery in 4/10 .
MEDICATIONS:
1. Albuterol nebulizers 2.5 mg every 12 hours
2. Aspirin 325 mg once daily.
3. Sarna.
4. Ciprofloxacin 250 mg twice a day The patient received two doses
prior to admission.
5. Colace 100 mg twice a day
6. Fluticasone one spray in each nostril twice a day
7. Lasix 80 mg every day before noon
8. Flovent two puffs twice a day
9. Subcutaneous heparin 5000 units three times daily.
10. Lispro sliding scale.
11. Lantus 32 units nightly.
12. Simvastatin 30 mg once daily.
13. Albuterol nebulizers as needed for shortness of breath and
wheezing.
14. Tylenol as needed.
15. Senna two tablets orally twice a day
16. Losartan 50 mg once daily.
17. Multivitamin once daily.
18. Iron 150 mg twice a day
19. Potassium chloride 40 mEq twice a day
20. Protonix 40 mg every 12 hours
21. Maalox as needed.
22. Dulcolax as needed.
23. Benadryl as needed.
24. MiraLax as needed.
ALLERGIES:
1. Sulfa ( swelling ).
2. Tetracycline ( swelling ).
SOCIAL HISTORY: The patient has a remote tobacco history. He
has a 40-pack-year history , quit 40 years ago. The patient uses
a walker and wheelchair at baseline.
BRIEF PHYSICAL EXAMINATION AT THE TIME OF ADMISSION: Vital
signs: Temperature 98.5 , heart rate 49 , blood pressure 160/56 ,
respiratory rate 18 , oxygen saturation 99% on room air , weight
94.3 kg. General appearance: The patient is in no acute
distress at present. HEENT: Oropharynx is clear. There is no
palatal petechiae. Pupils are equally round and reactive to
light and accommodation. There is no scleral icterus present.
Neck: Supple. There is no lymphadenopathy or masses present.
Cardiovascular: Rate is irregularly irregular. It is
bradycardic. There is a 2/6 systolic ejection murmur at the
right upper sternal border that is heard throughout. Jugular
venous pressure is distended and can be seen at the level of the
ear. Respiratory: There are bilateral basilar crackles.
Abdomen: Obese. There are positive bowel sounds. Abdomen is
soft , nondistended and nontender. No rebound tenderness or
guarding. Skin: There is no stigmata of endocarditis. There
are no splinter hemorrhages. No Osler nodes or red spots. There
is 1+ pitting edema of the bilateral lower extremities. There
are 1+ distal pulses in the upper and lower extremities
bilaterally. Neuro: The patient is alert and oriented x3 and
exam was nonfocal.
LABORATORY DATA: At the time of admission , sodium 144 , potassium
4.5 , chloride 106 , bicarb 30 , BUN 41 , creatinine 1.9 , glucose 83 ,
anion gap is 8. White blood cell count of 8.1 , hematocrit 31.7 ,
platelets 332 , 000. There are 71% neutrophils , 14% lymphocytes
and 12% monocytes. Calcium is 8.7. Urinalysis shows trace
blood , 3+ leukocyte esterase. 40-50 white blood cells , 1-5 red
blood cells , trace bacteria.
STUDIES AT THE TIME OF ADMISSION.
1. Chest x-ray shows status post midline sternotomy and CABG.
There is moderate enlargement of the cardiac silhouette , which is
unchanged from prior x-rays. Right lung is clear. There is a
small left posterior pleural effusion , which has been reduced in
size compared to his previous x-ray dated 8/29/07 .
2. EKG revealed an irregularly irregular rhythm with atrial
fibrillation with a rate of 44. There is left axis deviation , a
right bundle-branch block and Q waves in II , III and aVF , which
is unchanged from an EKG in 5/3 .
HOSPITAL COURSE BY PROBLEM: This is an 82-year-old gentleman
with a history of multiple medical problems most significantly
including recent aortic valve replacement for aortic stenosis , CAD
status post CABG , CHF , atrial fibrillation with a slow
ventricular response who was transferred from rehabilitation with
a fever , positive urinalysis and positive blood cultures with
concerns for endocarditis given his recent AVR. The patient was
initially started on ceftazidime and vancomycin empirically.
Blood cultures were obtained and the patient grew out
two out of two bottles of Gemella morbillorum from his blood.
Urinary cultures were also obtained , which revealed 10 , 000
colonies of Pseudomonas aeruginosa. Cultures were also taken
from the suprapubic catheter wound site and revealed rare MRSA ,
few coag-negative staph and rare enterococci. Once blood
cultures for Gemella morbillorum returned , the patient's
antibiotics were changed to gentamicin and ceftriaxone on
7/17/07 .  Ceftazidime was discontinued as was vancomycin. The
patient remained afebrile while inhouse and did not exhibit any
significant leukocytosis or stigmata of endocarditis.
Surveillance cultures obtained after starting antibiotics have
remained negative to date. A TTE was obtained and was negative
for any valvular vegetation. However , given the patient's high
risk for endocarditis , a TEE was obtained , which was also
negative for any ring abscess or valvular vegetation. The
patient , however , will be treated for endocarditis given his high
risk.
1. Cardiovascular:
Ischemia: The patient had no chest pain , chest tenderness or
chest discomfort. He does have a history CAD status post CABG
and was continued on his full strength aspirin. He was also
continued on statin.
Pump: The patient was volume overloaded at the time of admission
and was treated with 60 mg of intravenous Lasix. Following this , he
appeared euvolemic and Lasix was held for several days and then
gradually became volume overload and was again given 60 mg of intravenous
Lasix and then restarted on his home dose of 80 mg orally every day before noon. At the
time of discharge , the patient is slightly volume overloaded , but
diuresing well with 80 mg daily. The patient's Losartan was held
in the setting of his chronic renal insufficiency and initiation
of gentamicin therapy. At the time of discharge , his weight is
96.6 kg. His I/O goal at time of d/c is 500cc negative daily. He should
continue daily weights. Of note , the patient's dry weight is
approximately 93 kg. patient's lasix should be titrated as he reaches his dry weight.
Rhythm: The patient is bradycardic at baseline down into the
mid-to-low 30s , is asymptomatic and has in the past refused
permanent pacemaker placement. All nodal agents should be
avoided for this reason. The patient did have several runs of
nonsustained ventricular tachycardia upto 14 beats. Electrolytes
were checked twice daily to keep magnesium above 2 and potassium
above 4. However , no other medical management was initiated
given his bradycardia.
2. Infectious Disease: As noted above , there was high suspicion
for endocarditis in this with a recent AVR. He was found to have
Gemella morbillorum in his blood and was started as noted above
empirically on vancomycin and ceftazidime and then changed to
gentamicin and ceftriaxone on 7/17/07 once gram-positive cocci
were speciated. The patient was initially treated for
pseudomonal UTI with five days of ceftazidime , but given that
only 10000 CFUs grew out , it was decided that ceftazidime
could be discontinued and that there would be some response to
ceftriaxone plus gentamicin. A PICC line was placed on 7/17/07
for continued intravenous antibiotics and the patient should continue a
full six-week course of ceftriaxone and at least a two-week
course of gentamicin for presumed endocarditis despite
both negative transthoracic echocardiogram and transesophageal echocardiogram
given his high risk for endocarditis.
3. GI: The patient was continued on his home dose of Protonix
and all his stools were guaiaced and were negative in house. The
patient should be continued on as needed Colace.
4. Endocrine: The patient has a history of insulin dependent
diabetes mellitus. His Lantus was titrated up to 36 units
nightly and at that level required no sliding scale insulin.
5. Renal: The patient was found to have a slightly elevated
creatinine above his baseline on admission ( 1.9 with a baseline
of 1.1 to 1.3 ). This elevated creatinine was thought to likely
be due to his CHF and poor forward flow. As the patient was
diuresed , his creatinine decreased to 1.4 at the time of
discharge. Given his creatinine elevation , however , his Losartan
was held and this should be held while the patient is on gentamicin.
6. GU: The patient has a history of BPH and at the time of
admission had a suprapubic catheter that was inserted in 4/10
due to difficulty to pass Foley catheter. The catheter was
clamped and post-void residuals were checked and were only 50 mL
and the patient was urinating without difficulty with tube clamped ,
so Urology was consulted and suprapubic catheter was pulled
without difficulty. Suprapubic wound was dressed with a sterile
dry dressing to be changed daily.
7. Fluids , Electrolytes and Nutrition: The patient has a
current input and output goal of 0.5 L negative daily. He is on a 2L fluid
restriction.
Electrolytes. The patient has been having twice daily
electrolyte checks to keep his magnesium above 2 and his
potassium above 4 given his arrhythmias while he is on 80 mg of
Lasix daily. This should be continued.
Nutrition. The patient was placed on a cardiac , 2-gm sodium
diet and a 2 L fluid restriction.
8. Pulmonary: The patient is to continue on Flovent and
albuterol.
9. Heme: The patient was continued on Niferex twice daily for
iron deficiency anemia. He was also found to have a very mild
eosinophilia , which should be followed.
10. Derm: The patient was found to have a skin tear on his
right hand. This is being treated with neomycin ointment and
sterile dry dressing changes daily.
11. Prophylaxis: The patient was placed on subcutaneous heparin
5000 units three times daily and continued on his PPI.
CODE: The patient is full code.
PHYSICAL EXAMINATION AT THE TIME OF DISCHARGE: Vital Signs:
temperature 98.7 , blood pressure is 118-140/60-70 , heart rate
35-58 , respiratory rate 18-20 , oxygen saturation 94-100% on room
air , 100% on 2 L. Weight 96.6 kg. On general exam , the patient
is in no acute distress. Neuro: The patient is alert and
oriented x3. Pulmonary: There are decreased breath sounds a
quarter of the way up on the left lung field and there are
decreased breath sounds at the bases on the right lung field.
Cardiovascular: There is an irregularly irregular rhythm and
with bradycardia. There is a 2/6 systolic ejection murmur at the
right upper sternal border. JVP is 5-6 cm of water. Abdomen:
There are normoactive bowel sounds present. Abdomen is soft ,
obese , nondistended and nontender. Suprapubic catheter site is
without purulence or erythema. Extremities: There is 1+ pitting
edema to the shins bilaterally with chronic venous stasis changes
bilaterally. Skin: There are no rashes present. There are no
splinter hemorrhages or Osler nodes noted.
LABS AT TIME OF DISCHARGE: Sodium 141 , potassium 4.0 , chloride
108 , bicarbonate 26 , BUN 41 , creatinine 1.5 , glucose 164 , calcium
9.1 , magnesium 2.0 , hematocrit 29.2 , white blood cell count 8.9 ,
platelets 227 , INR 1.1 , PTT 38.1. There are 68% polys , 18%
lymphocytes , 7.1% monocytes and 5.9% eosinophils. Gentamicin
peak is 17.8 with a trough of 0.9.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg orally once daily.
2. Albuterol nebulizer2.5 mg nebulized every 6 hours as needed for
wheezing.
3. Albuterol nebulizer 2.5 mg nebulized every 12 hours
4. Dulcolax 5 mg orally daily as needed for constipation.
5. Ceftriaxone 2000 mg intravenous daily to be continued until 8/20/07 .
6. Gentamicin 80 mg intravenous daily to be continued at least until
7/25/07 .
7. Colace 100 mg orally twice a day
8. Fluticasone nasal spray one spray in each nostril twice a day
9. Flovent 110 mcg inhaled twice daily.
10. Lasix 80 mg orally every day before noon
11. Heparin 5000 units subcutaneously every 8 hours
12. Lantus 36 units subcutaneously at bedtime.
13. Lispro sliding scale subcutaneously before meals
14. K-Dur 40 mEq orally twice a day
15. Niferex 150 mg orally twice a day
16. Pantoprazole 40 mg orally every 12 hours
17. MiraLax 17 gm orally daily as needed for constipation.
18. Sarna topical to be used daily as needed for itching.
19. Senna two tablets orally twice a day
20. Simvastatin 40 mg orally at bedtime.
21. Multivitamin with minerals one tablet orally daily.
22. Bacitracin ointment to be applied to right hand lesion
twice a day
DISPOSITION: The patient will be discharged to rehabilitation.
At the time of discharge , there are two blood cultures that are
no growth to date but needs to be followed up.
FOLLOWUP PLANS:
1. The patient is to have a basic metabolic panel checked twice
daily while he IS actively diuresing with Lasix and after this
time , should have basic metabolic panel checked at least twice
weekly to follow electrolytes and creatinine while he is on
antibiotics.
2. Please draw a CBC with differential at least once weekly
while he is on gentamicin and ceftriaxone.
3. Please draw a gentamicin trough once weekly and adjust
gentamicin doses as needed.
4. Infectious disease consultant is to determine whether to the
gentamicin should be continued beyond two weeks.
5. Consider surveillance blood cultures one week after
completing antibiotic therapy to document clearance.
6. Please place neomycin ointment to right hand lesion daily and
cover with sterile dry dressings to be changed daily.
7. Continue dry sterile dressing to the suprapubic catheter site
to be changed daily until the wound is healed.
8. Consider repeat urine cultures two weeks after time of
discharge to document clearance of pseudomonal UTI.
9. Would hold off on restarting Losartan until gentamicin is
discontinued.
10. Please follow up all pending blood cultures.
FOLLOWUP APPOINTMENTS:
1. Appointment with Dr. Dulcie Scovel in the Infectious Disease
Clinic at Petersram Medical Center on 9/5/07 at 8 a.m.
The patient was discharged at a weight of 96.7 kilograms. His
dry weight is approximately 93 kilograms. His In's and Out goals
should be -500 cc daily. He is currently on Lasix 80 mg in the
morning.
eScription document: 0-5568862 CSSten Tel
Dictated By: YEAGLEY , MA
Attending: FANIEL , GAYLENE
Dictation ID 9295051
D: 3/10/07
T: 3/10/07

Document id: 14

756484975 | PUO | 14374811 | | 2938559 | 1/26/2007 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 6/11/2007 Report Status: Signed

Discharge Date: 1/26/2007
ATTENDING: THEILING , BREE MD
SERVICE:
Cardiology.
PRINCIPAL DIAGNOSIS:
Coronary artery disease.
LIST OF PROBLEMS:
1. Coronary artery disease.
2. Status post MI.
3. Diabetes mellitus.
4. Hospital-acquired pneumonia.
HISTORY OF PRESENT ILLNESS:
Mr. Daughtrey is a 75-year-old female with diabetes , coronary artery
disease , status post CABG in 1995 , recent MIBI , stress test in
July with a small area of reversible ischemia inferiorly who had
peripheral vascular disease , right CVA status post IVC filter for
DVT , triple AAA , status post repair , COPD , who presented to
Norap Valley Hospital with nausea of unclear source and deep lateral
T wave inversions in EKG leads V2-V6. She has noted intermittent
fevers at home to 102 and sent into the Norap Valley Hospital by her
VNA. Please see discharge summary from Norap Valley Hospital for
more details. She was at that time on treatment for a left foot
diabetic ulcer on Augmentin. Over the last week prior to
admission , she had increasing nausea , diarrhea without abdominal
pain. She did have mild fevers and increased cough though she
had no chest pain , orthopnea or urinary complaints. At the
Norap Valley Hospital , they noted that she had deep T-wave inversions
laterally and she was ruled out for DCS by cardiac enzymes. They
transferred her to Pagham University Of for consideration
of cardiac catheterization.
PAST MEDICAL HISTORY:
1. Type II diabetes complicated by peripheral neuropathy.
2. Coronary artery disease status post CABG in 1995.
3. Congestive heart failure.
4. COPD.
5. Peripheral vascular disease.
6. Hypertension.
7. Chronic kidney disease.
8. Abdominal aortic aneurysm , status post repair.
9. Carotid disease status post right CEA.
10. DVT status post IVC filter.
11. Diverticulitis , status post sigmoid colectomy.
12. Gout.
13. Left foot diabetic ulcer , has been treated with multiple
different antibiotic courses including levofloxacin , Flagyl , and
nasalide , as well as Augmentin.
MEDICATIONS PRIOR TO ADMISSION:
1. Augmentin 875 mg orally twice a day
2. OxyContin 8 mg orally three times a day as needed
3. Tylenol as needed.
4. Tessalon perles as needed
5. Ativan 0.5 at bedtime as needed
6. Atrovent nebulizer as needed
7. Lasix 30 mg orally daily.
8. Glipizide 2.5 mg orally daily.
9. Gabapentin 300 mg orally three times a day
10. Multivitamin.
11. Atenolol 25 mg orally daily.
12. Allopurinol 100 mg orally daily.
13. Aspirin 81 mg daily.
14. Lipitor 40 mg daily.
ALLERGY/ADVERSE DRUG REACTIONS:
1. Sulfa , the allergic reaction is unclear , although it has
noted anaphylaxis on previous discharge summaries.
2. Theophylline causes tongue swelling.
3. Quinine reaction unclear.
4. Iodine/intravenous contrast. This is noted in the medical record.
However , the patient does not remember having an adverse reaction
or allergic reaction to intravenous contrast.
5. Iron , this reaction is unknown.
6. Erythromycin , again , the patient does not remember any
reaction , but apparently has hives.
7. Levofloxacin , unclear what the reaction is. She has
tolerated this in April , which she was treated for a foot
ulcer. It is not clear if this is a rash or it was thought to be
possibly related to a fever that the patient had , but it is not
clear what the actual reaction is.
SOCIAL HISTORY:
The patient is an 80-pack-year smoker. He is currently smoking.
PHYSICAL EXAM ON ADMISSION:
Her temperature was 99 , her pulse was 98 , her blood pressure was
105/55. Her respiratory rate was 18 when she was saturating 94%
on room air. In general , she is in no acute distress. Her HEENT
exam was unremarkable. Her cardiac exam was regular rate and
rhythm with a 2/6 systolic murmur at the apex. Her lung exam was
notable for crackles most prominent in the left lower lobe. Her
abdomen was soft , obese , nontender and nondistended with good
bowel sounds. Her extremities were significant for erythema of
the left shin without warmth or tenderness. She also had a small
1.5 cm ulceration on the bottom of her left foot which has been
present for sometime although she says that it looks better than
at first. There was no purulence or purulent drainage from the
wound. Her neurologic exam was unremarkable.
LABORATORY DATA ON ADMISSION:
Her labs were notable for a creatinine of 1.6 , a white count of
4.1 , with 11% eosinophils. Her hematocrit was 31.6 , and her
albumin was 3.
PROCEDURES:
Cardiac catheterization: it was done by Dr. Wero .
FINDINGS:
Showed a right dominant circulation. There were no significant
left main lesions identified. The LAD had a tubular 90% lesion
and the diagonal I had a proximal tubular 60% lesion , there was
also a diffuse 80% lesion of the proximal circumflex. The RCA
had a proximal 75% lesion with a mid diffuse 60% lesion and a PLV
tubular 70% lesion. The coronary artery bypass grafts had a
patent LIMA to LAD graft , the SVG to marginal I had a 100% lesion
during this catheterization due to the moderate amount of
contrast and the patient's chronic kidney disease , they treated
the RCA and placed a 3 x 24 mm Taxus stent
ECHOCARDIOGRAM:
On 7/9/07 , showed an estimated ejection fraction of 50% with
inferoseptal and inferior severe hypokinesis. The RV was normal.
There was mild aortic stenosis. Mild-to-moderate aortic
regurgitation. The valve area was 1.2 cm2. There was mild
mitral regurgitation. There is trace tricuspid regurgitation
with a pulmonary artery systolic pressure of 36 mm plus right
atrial pressure.
HOSPITAL COURSE BY PROBLEM:
1. Cardiovascular:
a. Ischemia: The patient was admitted because they had deep T
wave inversions in the lateral leads and are still concerning for
anginal equivalence of nausea and vomiting. It was decided on
admission that an echocardiogram would be performed and if there
was evidence of any regional wall motion abnormalities that she
would be taken directly to cath. The echocardiogram as noted
above showed inferior hypokinesis consistent with coronary artery
disease. She was taken to the cath lab on 9/5/07 and they show
two ____ that one of the bypass grafts was completely occluded
and was not visualized. They also saw that there was a proximal
RCA lesion 60% which was found to account for the inferior
hypokinesis given the right arm circulation. This was stented
with a Taxus stent. Because of her kidney insufficiency , it was
decided not to pursue the 80% left circ lesion and this was
deferred until later point as this was not thought to be causing
any problems. Her post cath ECG was unchanged and continued to
have the deep lateral T wave inversions. She did not complain of
any chest pain or nausea and vomiting during her admission. She
was started on aspirin and Plavix initially although as noted
below she did have an apparent allergy to Plavix and thus was
switched to ticlopidine 250 mg twice a day instead of Plavix for
anticoagulation. She was also continued Lipitor 80 mg daily ,
Lopressor 25 mg three times a day After her cath , it was originally planned
that she would go back to cath for intervention on the left
circulation lesion , however , given her other medical problems and
her relative stability hemodynamically and symptomatically , it
was decided that they would wait and decide later if this lesion
needed to be corrected in the future or not.
b. Pump: The patient had no significant issues with her blood
pressure here. She remained in a blood pressure range of 100-120
throughout her stay. She was continued on her beta blocker as
noted above. However , at discharge , this was switched back to
atenolol as her home medications and she refused to change
medications , she said that she would not be able to afford new
prescription. We did increase her dose of atenolol to 25 mg
twice a day from 25 mg daily as her requirement of beta blockade
seemed to be higher than what her home dose was. Given that she
has a concurrent renal disease , it would probably be useful for
her to be on an ace inhibitor ARB as well. This medication
should be added as an outpatient , if her blood pressure tolerates
it. It was on the lower side here , so we did not add it. We did
not diurese her in fact we held her Lasix on admission because
she seemed to be volume depleted given that she was admitted with
a lot of diarrhea , this again will need to be reconsidered if she
had increased edema. This can be restarted.
C: Rhythm: The patient was kept on telemetry , however , there
were no significant episodes of arrhythmias during her admission.
2. GI: The patient was admitted with persistent nausea and
diarrhea from Norap Valley Hospital .  The diarrhea resolved one day
after admission. Her fecal leukocytes were positive but her C.
diff was negative. It was unclear what the etiology of this
diarrhea was and we were going to send a repeat stool study ,
however , she did not have any diarrhea afterwards and this may be
antibiotics associated diarrhea but it seemed to resolve
spontaneously.
3. Pulmonary: The patient was admitted with crackles in the
left lower lobe and some wheezing consistent with COPD and
pneumonia. A chest x-ray on admission showed a right lower lobe
infiltrate/atelectasis. We initially continued her on Augmentin ,
which she was taking for her diabetic foot ulcer. However , she
did not appear to clinically respond to this medication. We held
her antibiotics as noted below in the ID section and after that
her white blood cell count increased and she produced some
purulent sputum and Gram-negative rods. The Gram-negative rods
were later speciated as serratia although this information is not
available at the time of her discharge. She was treated for a
hospital-acquired pneumonia with vancomycin and ceftazidime to
complete a 14-day course. Clinically , she appeared to improve on
this regimen , although her white count was still elevated at 15
on discharge , however , given her overall clinical stability , the
lack of fevers and the lack of systemic symptoms. We felt
comfortable with discharging her with close follow up.
4. Infectious disease: The patient was initially admitted on
Augmentin for a diabetic foot ulcer , the notes from Norap Valley Hospital by the Infectious Disease Service recommended a 2-4 week
course of Augmentin for her diabetic foot ulcer. She had
completed three weeks of therapy and thus we discontinued this
medication as it did not seem that there was really any evidence
of active infection in her foot. After holding the antibiotics
for three days , her white count began to rise and she developed a
purulent cough as noted above , this was thought to be a
hospital-acquired pneumonia. She was treated with vancomycin and
ceftazidime and she will complete a 14-day course of these
antibiotics.
5. Endocrine: The patient was home on orally hypoglycemics. She
was switched to coverage with an insulin scale. Her sugars were
relatively well controlled and she did not require much in the
way of supplemental insulin.
6. Renal: The patient has chronic kidney disease. Her baseline
creatinine was 1.5-1.6. She was admitted and had a cath. She
was given Mucomyst and bicarbonated fluids for renal protection
during her dilute. Because of the risk for kidneys , the cath was
done with a little amount of dye as possible. Her creatinine
remained stable throughout her admission and settled out at 1.6
of her creatinine which is the baseline.
ALLERGY:
During the patient's admission , it was noted that she developed a
rash on 4/15/06 .  She was seen by the Allergy and Immunology
Service at the request of the cath lab given that there was
concern that she had this rash because of her Plavix. They felt
that this was possible. This was the most likely etiology and in
conjunction with her high eosinophil count it was felt that this
was a drug reaction to the Plavix. She was switched to
ticlopidine 250 mg twice a day and her rash appeared to improve. She
was also given claritin as well as put on a brief prednisone
taper given her diffuse rash and her brisk eosinophilia. She
should follow up with Allergy and Immunology in about one month
to see if the rash has resolved and potentially to try
rechallenge with Plavix at that point.
Cellulitis/diabetic foot ulcer: The patient has had a
longstanding diabetic foot ulcer which has been treated by wound
care VNA and was treated at Norap Valley Hospital .  We continued the
Augmentin to a total course of three weeks and then stopped it.
We continued her dressing changes and this will be followed by
the VNA at home. There was no evidence of active infection ,
there was no purulence or erythema around the area of the ulcer
and the erythema around the foot appeared to be stable , this was
most likely chronic venous stasis change and not a true
cellulitis as there was no warmth or tenderness in this region.
CONSULTANTS:
Allergy/Immunology , the attending was Dr. Biggins .
PHYSICAL EXAM AT DISCHARGE:
The patient was afebrile. Her pulse was 86 , her blood pressure
was 120/60 , her respiratory rate was 20. She was 92-96% on room
air. In general , she was in no acute distress. Her JVP was
about 7 cm. She had small amount of crackles at bilateral bases.
Her cardiac exam was regular rate and rhythm with normal S1 and
S2. There was a 2/6 systolic murmur most prominent at the left
lower sternal border. Her abdomen is soft , nontender , and
nondistended with good bowel sounds. She had 1+ edema
bilaterally with small amounts of erythema at the distal end of
the left lower extremity which has been stable. There is no
associated warmth or tenderness. She did have a 1.5 cm small
ulcer on the ventral aspect of her left foot , which did not have
any purulence associated with it. Her neurologic exam was
nonfocal.
LABORATORY DATA ON ADMISSION:
Notable for a creatinine of 1.5 , a white blood cell count of
15.89 , with 82.7% neutrophils , 3.8% eosinophils. Her hematocrit
was 28.6. Her baseline appears to be around 30.
DISCHARGE MEDICATIONS:
1. Ticlopidine 250 mg by mouth twice a day.
2. Atenolol 25 mg by mouth twice a day
3. Lipitor 80 mg daily.
4. Prednisone taper 30 mg on 10/18/07 , 20 mg on 10/3/07 , 10 mg
on 10/18/07 and then stop.
5. Vancomycin 1 g intravenous daily , course to be completed on 1/16/07 .
6. Ceftazidime 1 g daily to be complete on 1/16/07 .
7. Allopurinol 100 mg daily.
8. Neurontin 300 mg three times a day.
9. Tessalon perles as needed.
10. Ativan 0.5 mg at bedtime as needed for sleep.
11. Glipizide 2.5 mg daily.
12. DuoNeb every 4 hours as needed for shortness of breath.
13. Lasix 30 mg by mouth daily.
14. Aspirin 81 mg daily.
DISPOSITION:
Home with services.
PENDING TESTS:
As noted , the patient had a sputum culture that was growing
Gram-negative rods at the time of discharge. The current report
is that it was growing Serratia marcescens which should be staph
sensitive to ceftazidime , which he was prescribed for a total of
14 days.
FOLLOW UP:
She will follow up with Dr. Katheryn Gruntz on 10/12/07 at 9:30
a.m. She has an appointment scheduled.
TO DO LIST:
1. The patient has an 80% left circumflex lesion which was not
stented. This should be , ___28.20__ , whether she needs a second
intervention in the future. She does appear to be asymptomatic ,
but she does continue to have the deep lateral T wave inversion
suggesting the areas of abnormal blood flow in the heart. It was
thought that the right RCA lesion was more likely to be the cause
of her inferior wall hypokinesis , so that was the procedure
performed.
2. The patient was treated for hospital-acquired pneumonia with
vancomycin and ceftazidime. This will continue until 1/16/07 .
She was noted to have a rash here which was thought to be Plavix
related. If the rash resolves on ticlopidine , she may need to
readdress whether or not this was actually due to Plavix. It was
recommended that she follow up with an allergist in about a month
from her hospitalization who can review the records and determine
whether she should start Plavix or maintain on the ticlopidine.
3. Her platelets should be monitored given that she started on
ticlopidine and there is a risk of TTP associated with this
medication.
eScription document: 0-4690211 EMSSten Tel
CC: Katheryn Gruntz M.D.
Menlandlourdes Medical Center
Ry Ale Sa
Dictated By: WOODRUM , ELOY
Attending: THEILING , BREE
Dictation ID 9850445
D: 10/3/07
T: 10/29/07

Document id: 15

659753603 | PUO | 48763358 | | 201016 | 6/29/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/1/1995 Report Status: Signed

Discharge Date: 10/25/1995
PRINCIPAL DISCHARGE DIAGNOSIS: FEVER , STATUS POST CARDIAC
TRANSPLANT
OTHER DIAGNOSES: 1 ) HEMOLYTIC ANEMIA; 2 ) THROMBO-
CYTOPENIA
HISTORY OF PRESENT ILLNESS: Mr. Breckenridge is a 50 year old
male who is ten years status post
cardiac transplant for an ischemic cardiomyopathy , who presents
with a five week history of a flu like illness and fevers. Cardiac
transplant was in 1985 without complications and in 1989 he had one
episode of herpes zoster , and was treated for cataract. He
remained stable without cardiac symptoms or exertional limitation.
Last had a cardiac catheterization in April of 1994 , showed no
evidence of coronary artery disease , normal LV size and function ,
normal RV and trace MR. Right heart catheterization on 7/10 showed
normal hemodynamics. There was no evidence of rejection on biopsy.
There was no history of signs or symptoms localizing infectious
process until about five weeks prior to this admission when he
developed a flu like symptom , including a dry cough , occasionally
productive of whitish sputum , general malaise , nasal congestion
with occasional blood streaked secretions , arthralgias and fatigue.
He also reports dyspnea on exertion after one flight at moderate
pace with occasional night sweats and loose stools. Multiple family
members were ill with similar symptom complexes. The patient took
one week off from work and felt that he was getting better until
approximately 24 hours prior to admission when he again had
increased weakness , muscle and joint aches , fevers to 101.2 orally ,
shaking chills , continued dry cough and headache. Diarrhea
spontaneously resolved but has had persistent dyspnea on exertion.
The patient denies any PND , orthopnea , chest pain , nausea and
vomiting. Has had anorexia with a 15 pound weight loss in the past
month. He is currently being admitted for evaluation and management
of his flu like illness following his cardiac transplant. He is
immunosuppresed with Cyclosporin , Prednisone and Imuran.
PAST MEDICAL HISTORY: 1 ) Cardiac transplant; 2 ) hyper-
tension; 3 ) status post bilateral
cataract surgeries; 4 ) herpes
zoster flare.
MEDICATIONS ON ADMISSION: 1 ) Vasotec , 10 mg twice a day;
2 ) Mevacor , 20 mg every day; 3 ) Imuran ,
150 mg every day; 4 ) Diltiazem CD , 180 mg every day; 5 ) Prednisone , 10 mg every
day; 6 ) Aspirin , 325 mg every day; 7 ) Cyclosporin , 100 mg twice a day; 8 )
Magnesium; 9 ) Robitussin as needed. The patient has no known drug
allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: He smoked one pack per day. Denies
alcohol use.
PHYSICAL EXAMINATION: The patient is a middle aged male in
no apparent distress. Temperature is
99.3 degrees orally Pulse is 102 and regular. Breaths are 16 , even
and unlabored , 97% oxygen saturation at room air and blood pressure
is 120/76. His skin was within normal limits , mild scleral icterus.
Jugular venous pressure was 6 cm. Carotids were 2+ bilaterally
without bruits. There is no thyromegaly or adenopathy. His lungs
were clear bilaterally. Cardiac exam revealed a normal S1 and S2.
There are no murmurs , gallops or rubs. There is a regular rate and
rhythm. His PMI was non displaced. Abdomen was soft and non tender ,
non distended , normoactive bowel sounds with no hepatosplenomegaly.
Extremities without cyanosis , clubbing or edema or rashes. Distal
pulses were 2+ bilaterally and neurological exam was completely non
focal.
LABORATORY DATA ON ADMISSION: Of significance , BUN was 27 ,
creatinine 1.8 , white blood cells
were 5.3 , with 71% PMNs and 10% bands , 4% lymphocytes , 8% monocytes
and 4% eosinophils. Platelet count was depressed at 90 , 000 ,
hematocrit was low at 30%; LDH was 302 and elevated; bilirubin was
elevated at 2.2 , total over 1.1 direct and Cyclosporin level on
admission was 276. Admission chest x-ray showed enlarged
mediastinal silhouette. There was no infiltrates or effusion. EKG
showed sinus tachycardia , rate of 106; axis was +6 degrees ,
intervals were .14/.08/.30 and RSR prime in V1 anterior T wave
inversion. There were no acute changes. His blood smear showed no
evidence of hemolysis. There are no schistocytes.
HOSPITAL COURSE: This is a 50 year old gentleman who
is ten years status post cardiac
transplant , who presents with waxing and waning flu like illness
with fevers and left shift. Of note is hyperbilirubinemia with an
elevated LDH , in conjunction with anemia , suggestive of hemolysis
and also thrombocytopenia. It was felt that patient most likely
had an infectious process. Infectious Disease was contacted. The
patient had multiple blood cultures , sputum cultures , sputum
analyses and titers drawn with a completely negative workup , except
for E. coli noted on several sputum stains but there is no other
evidence for pneumonia. The patient was empirically treated for
several days on intravenous Cefuroxime with no change in his fever
curve , which had ranged from 100 to 102 degrees for all the days of
admission except the last 24 days of admission when patient was
afebrile. Most likely explanation for the patient's symptoms and
signs is a viral illness of unclear etiology. The fevers , joint
aches , upper respiratory symptoms all resolved by the time of
discharge. With regards to the patient's anemia , there was no
specific diagnosis made , despite extensive workup. The hematology
oncology service was consulted , and stated that the patient's
peripheral smear was normal , as it had been by our reading. They
still wanted to check a PNH screen and G6PD level in three to four
weeks following discharge for possible explanations of his
hemolytic anemia , although may be possibly related to a viral
illness as well. By the time of discharge , the patient's
hematocrit was stable at 30% and there was no further increase in
the patient's LDH or bilirubin; in fact those levels were resolving
by the time of discharge. The thrombocytopenia again may be
related to the viral illness and there is no evidence for hemolytic
uremic syndrome or microangiopathic hemolytic anemia. Also during
this visit , a PPD was checked and it was found that the patient was
anergic , as might be expected with all of his immunosuppressive
drug regimen. At the time of discharge , the patient was feeling
well and no longer complaining of his flu like syndrome.
DISCHARGE MEDICATIONS: 1 ) Aspirin , 81 mg orally every day; 2 ) Cyclo-
sporin , 100 mg orally twice a day; 3 )
Colace , 100 mg orally twice a day; 4 ) Vasotec , 10 mg orally twice a day; 5 )
Mevacor , 20 mg orally every day; 6 ) Magnesium oxide , 420 mg orally every day; 7 )
Prednisone , 10 mg orally every day before noon; 8 ) Diltiazem CD , 180 mg orally every day; 9 )
Imuran , 150 mg orally every day
CONDITION ON DISCHARGE: Good
DISPOSITION: The patient was discharged to home ,
feeling well and was no longer
complaining of symptoms. He will follow up with Dr. Fernande Prewer
in cardiac transplant clinic in several weeks time. The patient
will call for the appointment.
Dictated By: FRANCISCA URBANIAK , M.D. CL8
Attending: SHAVONNE D. MAINER , M.D. WG5  ZN499/0449
Batch: 2594 Index No. HGEINX79OJ D: 4/17/95
T: 4/17/95

Document id: 16

068885322 | PUO | 41618858 | | 5143339 | 10/23/2006 12:00:00 a.m. | CHF exacerbation | | DIS | Admission Date: 1/6/2006 Report Status:

Discharge Date: 6/13/2006
****** FINAL DISCHARGE ORDERS ******
TORTORELLA , KASHA 340-64-18-9
Na More Ceanan
Service: ETMCH
DISCHARGE PATIENT ON: 2/5/06 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NOLAN , BYRON S.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally DAILY
Override Notice: Override added on 3/9/06 by
CRAGER , MARYANNE , M.D.
on order for COUMADIN orally ( ref # 296891962 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: needs
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
Instructions: POST-MI
Override Notice: Override added on 3/9/06 by
CRAGER , MARYANNE , M.D.
on order for COUMADIN orally ( ref # 296891962 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: needs
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
LASIX ( FUROSEMIDE ) 20 MG orally DAILY
LISINOPRIL 15 MG orally DAILY HOLD IF: SBP<90
Override Notice: Override added on 3/9/06 by
CRAGER , MARYANNE , M.D.
on order for SPIRONOLACTONE orally ( ref # 049035301 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL &
SPIRONOLACTONE Reason for override: needs
METFORMIN 500 MG orally twice a day
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
100 MG orally DAILY Starting IN a.m. ( 10/5 )
HOLD IF: sbp<100 , heart rate<60 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
SPIRONOLACTONE 25 MG orally DAILY
Food/Drug Interaction Instruction Give with meals
Alert overridden: Override added on 3/9/06 by
CRAGER , MARYANNE , M.D.
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL &
SPIRONOLACTONE Reason for override: needs
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Alert overridden: Override added on 2/5/06 by :
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: needs
COUMADIN ( WARFARIN SODIUM ) 2 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 2/5/06 by :
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
WARFARIN Reason for override: patient home medicatin
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally DAILY
FOLLOW UP APPOINTMENT( S ):
primary care physician DR STEPANIE TIJUANA LOBAN ( 501 ) 689-2198 8/19/06 @ 3:50 PM ,
CARD DR JONTE ( 376 834-1084 4/7/06 @ 1:00 PM ,
CARD DR GRINSTEAD ( 048 ) 968-4013 CLINIC WILL CONTACT ,
Arrange INR to be drawn on 7/7/06 with f/u INR's to be drawn every
percoumadinclinic days. INR's will be followed by PUO coumadin clinic
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
CHF exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD ( coronary artery disease ) HTN ( hypertension ) dyslipidemia
( dyslipidemia ) history of STEMI DM ( diabetes mellitus ) LV mural thrombus 1/13
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
IDENTIFICATION: 73F with a history of recent anterior STEMI ( 9/22 ) c/b apical
aneurysm , apical thrombus , and ischemic cardiomyopathy with most recent EF
35% admitted from home with increasing DOE and fatigue.
HISTORY OF PRESENT ILLNESS:
Mrs. Tortorella is a lovely 73yo woman who presented in 9/22 with 3 days of
epigastric and chest pain and was found to have a STEMI. She
subsequently underwent DES to ramus and LAD. Flow through the LAD was
only TIMI 2 by the end of the procedure. Course was complicated by
post-MI pericarditis , apical wall thinning , and mural LV thrombus.
She was discharged initially to short-term rehab , then subsequently went
home with weekly f/u with cardiac rehab. While at short term rehab , she was
treated with doses of lasix as high as 120 mg intravenous. Following discharge from
rehab , she was ultimately taken off of diuresis b/c of "dizzy spells" she
was experiencing while on lasix.
She did well off lasix until 2 weeks ago , when she was noted to have
decreased exercise tolerance and increasing fatigue at cardiac rehab.
She says that she is usually able to ambulate for 15 minutes on the
treadmill; she hasn't been able to do this for the past 2 weeks b/c of
dyspnea and fatigue. This has been accompanied by new-onset PND
( occurring as frequently as 3-5 times/night ) , 5 pound weight gain , and
increasing abdominal girth. She does acknowledge dietary indiscretion
this past week ( had a can of mushroom soup 4 days ago ). No orthopnea.
Mrs. Lobello cardiac rehab. contacted Dr. Jonte ( her primary
cardiologist ) a few days ago to inform her about Mrs. Lobello DOE and
increasing fatigue. Starting 2 days ago , she was placed on lasix 40 mg.
Since then , she has taken a total of 5 doses. She came to urgent care
this PM and was noted to desat. to 85% with ambulation in the setting of
fluid overload. She was subsequently admitted.
PAST MEDICAL HISTORY:
1. STEMI , 9/22 history of PCI to LAD with DESx2 c/b apical aneurysm ,
apical thrombus ( on coumadin ) , and ischemic cardiomyopathy ( with latest EF
35% )
2. Type 2 diabetes mellitus , on insulin
3. HTN
4. Dyslipidemia
ALLERGIES: NKDA
HOME MEDICATIONS:
1. Metformin 500 mg orally twice a day
2. Multivitamin 1 tablet orally every day
3. ASA 81 mg orally every day
4. Lipitor 80 mg orally every day
5. Plavix 75 mg orally every day
6. Tramadol 50 mg orally 6H
7. Insulin lantus 23 U subcutaneously qAM
8. Insulin aspart 8 U subcutaneously qAC
9. Insulin aspart sliding scale
10. Lisinopril 15 mg orally every day
11. Toprol XL 100 mg orally qAM
12. Coumadin 2 mg orally every day
13. Spironolactone 25 mg orally every day
14. Protonix 40 mg orally every day
15. Lasix 40 mg orally every day
SOCIAL HISTORY: Lives with her husband. Distant and minimal 5-6 pack
year smoking history ( quit ~12 years ago ). No EtOH.
PHYSICAL EXAMINATION AT ADMISSION
Tc 98; P 88; BP 136/84; O2 sat 97% , RA
NAD , well-appearing
JVP~8 cm
CTAB
PMI laterally displaced. RRR. S1 and S2 normal intensity. No rubs ,
murmurs , gallops.
+BS. ND/NT.
WWP. No edema.
LABORATORY DATA AT ADMISSION:
1. Na+ 144; K+ 4.1; Cl- 105; CO2 31; BUN 20; creatinine 1.0; glucose
73
2. ALT 40; AST 27; ALK 61; TB 0.4
3. CK 117; CKMB 1.6; troponin <assay
4. Ca2+ 9.7; Mg2+ 1.6
5. WBC 6.62; Hct 35.9; PLT 213
RELEVANT STUDIES:
EKG: NSR. Q waves in II , III , and aVF; along with V1-V4
CXR: Mild pulmonary vascular congestion
7/5/2006 ECHO: Mildly dilated left ventricle ( systolic diameter: 3.57
cm and diastolic diameter: 5.89 cm ). Overall left ventricular function
moderately reduced with EF 35%. Anteroseptal wall is akinetic from
midventricular level to apex , and hypokinetic at the base. Focal basal
inferior aneurysm ( new from 7/5/05 ) and the apex is focally
aneurismal. False tendon , but no obvious thrombus seen. Global right
ventricular systolic function mildly reduced. Trace TR. Trace TR. PASP
17 mmHg+RAP.
11/26 ETT: Duration 3'20'' and stopped d/t fatigue. Attained 4.7 METS.
Maximum heart rate 125 at 85% of predicted. Maximal blood pressure
130/70. ECG ST changes of accentuation of baseline ST , T wave
abnormalities. Apparently , low HR recovery. Imaging with large myocardial
scar in the proximal LAD territory. Small and mild myocardial ischemia
in the OM territory ( small defect involving the basal inferolateral
wall ). Post-stress EF 31%.
OVERALL ASSESSMENT: 73F with a history of recent anterior STEMI ( 9/22 ) c/b
apical aneurysm , apical thrombus , and ischemic cardiomyopathy with most
recent EF 35% admitted from home with increasing DOE and new-onset PND.
Appears to be fluid overloaded , improved with diuresis over 3 day
hospitalization.
HOSPITAL COURSE BY PROBLEM:
1. CARDS PUMP: Volume overloaded with ischemic CMP implicated.
Initially received intravenous diuresis with lasix 80 mg intravenous twice a day and was ~2.5 liters
negative. SBP down to 80 following overdiuresis on 6/14 held diuresis
on 10/7 .  Resumed orally regimen with lasix 40 mg orally every day on 10/5 .
Discharged on lasix 20 mg orally every day. Continued spironolactone 25 mg orally
every day. Increased lisinopril to 30 mg orally every day to optimize heart
failure regimen at admission; changed to 15 mg orally every day on 10/7 after
SBP dropped to 10/7 .  Also , she had apparently been taking this
inconsistently as well.
2. CARDS ISCHEMIA: No active issues. Recent ETT with small reversible
defect involving the basal inferolateral wall. Continued ASA , plavix ,
lipitor.
3. CARDS RHYTHM: W/ known ischemic cardiac disease and EF~35% ( down
to 31% on post-stress by MIBI ) , inclined for AICD placement ( MADIT ).
Discussed with EP and she will see Dr. Grinstead as an outpatient. Repeat Echo
4/3/06 with estimated EF 40%. Defer decision on EP eval to primary
cardiologist Dr. Jonte
4. PULM: Hypoxia in the setting of volume overload. Weaned O2 with
adequate diuresis.
5. HEME: 9/22 course c/b LV thrombus , has been on
anticoagulation. Repeat echo. without thrombus , however apex quite akinetic
and contrast study with stagnant flow concerning for high risk of thrombus
recurrence. Therefore , warfarin was continued in addition to ASA and
plavix. The decision to continue these three medications is deferred to
patient's primary cardiologist , Dr. Jonte . patient has INR drawn locally but is
managed by the PUO coumadin clinic and will f/u with them.
6. ENDO: Initially on regimen of lantus , lispro , and sliding scale.
Then patient acknowledged that she had never been on insulin the past.
Switched to sliding scale alone , transferred on metformin 500 mg orally twice a day
7. PPX: PPI and on coumadin until discharge.
8. CODE: FULL
*******
LABS AT DISCHARGE:
1. WBC 6.84; Hct 36.8; Platelets 228
2. Na+ 141; K+ 4.6; Cl- 106; CO2 31; BUN 37; creatinine 1.0; glucose 90
3. Ca2+ 9.2; Mg2+ 2.1
4. INR 1.6
5. HDL 48/triglycerides 60
During d/c patient questioned lasix dose was reasurred dose change to 20mg orally
qday. patient produced medication list which was different from discharge meds.
patient refused to stay to have medications rectified on d/c summary and left
without signing d/c summary. patient will be contacted in am to go over
instructions new medications. Attending and primary cardiologist notified.
ADDITIONAL COMMENTS: PLEASE CONTACT URGENT CARE ON 7/3 TO BE SEEN BY 1/12 FOR BLOOD WORK
( CREATININE AND ELECTROLYTE CHECK ). CALL AT ( 212 ) 019-1917.
If increasing SOB or development of CP , please seek medical attention
again.
Please measure and record daily weights. If increases by more than 3
pounds , please call Dr. Jonte .
Continue cardiac rehab. as before.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
( 1 ) Titrate lasix as appropriate
( 2 ) Check creatinine and serum electrolytes
No dictated summary
ENTERED BY: GUPTON , ANGELLA , M.D. ( OX65 ) 2/5/06 @ 06:52 PM
****** END OF DISCHARGE ORDERS ******

Document id: 17

362241745 | PUO | 66750039 | | 209406 | 1/30/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 9/20/1991 Report Status: Signed

Discharge Date: 2/12/1991
HISTORY OF PRESENT ILLNESS: CHIEF COMPLAINT was a 57 year old man
who was status post percutaneous
transluminal coronary angioplasty times 2 , of a left anterior
descending stenosis for unstable angina , and was admitted for new
onset of angina at rest. The patient's cardiac risk factors
included family history , borderline high cholesterol. The patient
had no prior cardiac history , until 12 of June , when he had substernal
chest pain with exertion. He eventually had cardiac
catheterization which showed an 80% proximal left anterior
descending lesion with thrombosis , good left ventricular function.
The patient had percutaneous transluminal coronary angioplasty to
this lesion. He was without symptoms for about 4 weeks , and then
in 23 of August , the patient noted new onset chest pain and left arm
numbness at rest. An electrocardiogram at that time showed sinus
bradycardia at 50 , T-wave inversions in II with flat T-waves in
III , and was otherwise unremarkable. He had an exercise tolerance
test at the time and went on a 9-minute standard Bruce protocol and
stopped secondary to fatigue. The electrocardiogram showed 3 to 4
millimeter ST depressions in the lateral leads , which was highly
predictive of coronary artery disease. At that time , he was repeat
cardiac catheterization which showed a restenosis of his left
anterior descending lesion. He had a repeat percutaneous
transluminal coronary angioplasty of the lesion without
complications. The patient did well for several weeks and was
pain-free. However , 6 days prior to admission , the patient began
to note occasional episodes of left arm numbness , which was always
relieved with sublingual nitroglycerin. There was no accompanying
dizziness , nausea , vomiting , diaphoresis. The patient at first had
2 or 3 episodes a day , now increased to 7 or 8 times a day at the
time of admission. On the day of adimssion , the patient had almost
constant chest pain and arm pain which lasted almost all day , only
partially relieved by sublingual nitroglycerin. The patient was
very concerned about the pain , and now comes to Pagham University Of for further evaluation. PAST MEDICAL HISTORY included
arthritis , kidney stones , chronic lower back pain. MEDICATIONS ON
ADMISSION were Lopressor 25 milligrams by mouth twice a day ,
aspirin 325 milligrams by mouth per day , Isordil 10 milligrams by
mouth 3 times a day. ALLERGIES included no known drug allergies.
SOCIAL HISTORY revealed the patient was a retired firefighter ,
occasional red wine , no tobacco use. His brother had 3 myocardial
infarctions in the past , no other FAMILY HISTORY.
PHYSICAL EXAMINATION: The patient was afebrile , pulse 54 , blood
pressure 104/70 , respirations 20. There was
no jugular venous distention. Chest was clear. Cardiac
examination showed regular rate and rhythm , normal S1 , S2 , no
peripheral edema. Extremities had good pulses bilaterally in
dorsalis pedis , posterior tibial and femoral.
LABORATORY EXAMINATION: Admitting laboratory values were
remarkable for potassium 4.3 , creatinine
1.0 , hematocrit 40.8. The electrocardiogram showed sinus
bradycardia at 50 , normal intervals , flat T-waves in AVF , V2 and
V3 , QRS axis 0 degrees. Chest x-ray showed no infiltrates or
effusions , no evidence of congestive heart failure.
HOSPITAL COURSE: The patient was admitted on a rule out myocardial
infarction protocol. He had no elevations in his
serum creatinine kinase levels. The patient continued to have
intermittent left arm numbness during his hospital stay. For this
reason , he was taken back for cardiac catheterization , which showed
a 75% proximal left anterior descending lesion believed to be at
the same site as his previous percutaneous transluminal coronary
angioplasty procedures. The patient had successful percutaneous
transluminal coronary angioplasty of the lesion with a 25% residual
stenosis. The patient postoperatively had no further episodes of
chest pain or arm numbness. He had no complications related to the
cardiac catheterization itself. The patient was then discharged.
DISPOSITION: The patient was discharged to home. MEDICATIONS ON
DISCHARGE will be Lopressor 25 milligrams by mouth
twice a day , Ecotrin 1 tablet by mouth per day , diltiazem 60
milligrams by mouth twice a day. The patient was to FOLLOW-UP with
his cardiologist in 1 week.
VH327/5150
KATHERYN SATURNINA GRUNTZ , M.D. WA5 D: 9/5/91
Batch: 5066 Report: H4292Q0 T: 3/9/91
Dictated By: NAOMI K. WOLFENSPERGER , M.D.

Document id: 18

076954946 | PUO | 61732093 | | 3296510 | 1/21/2006 12:00:00 a.m. | CHF EXACERBATION | Signed | DIS | Admission Date: 3/26/2006 Report Status: Signed

Discharge Date: 7/14/2006
ATTENDING: KATCSMORAK , CARRI MD
DISCHARGE DISPOSITION:
To Rehabilitation Hospital.
DISCHARGE MEDICATIONS:
Enteric-coated aspirin 325 mg orally daily , amiodarone 200 mg orally
daily , Colace 100 mg orally twice a day , insulin NPH 7 units every day before noon and
3 units every afternoon subcutaneously , Atrovent HFA inhaler 2 puffs
inhaled four times a day as needed for wheezing , magnesium gluconate sliding
scale orally daily , oxycodone 5-10 mg orally every 4 hours as needed pain ,
senna tablets one to two tablets orally twice a day as needed constipation ,
spironolactone 25 mg orally daily , Coumadin 1 mg orally every other
day , multivitamin therapeutic one tablet orally daily , Zocor 40 mg
orally daily , torsemide 100 mg orally daily , OxyContin 10 mg orally
twice a day , Cozaar 25 mg orally daily , Remeron 7.5 mg orally every bedtime , and
aspartate insulin sliding scale.
DISCHARGE DIET:
Discharge diet is 2 liters fluid restrict. Liberal house diet.
ADMISSION DIAGNOSIS:
Foot infection.
PRINCIPAL DISCHARGE DIAGNOSIS:
Decompensated congestive heart failure , status post bilateral
knee amputation , status post BKA.
RETURN TO WORK:
Not applicable.
FOLLOW-UP APPOINTMENTS:
Please follow up with primary care physician , Dr. Lizabeth Warpool , at
Loburg Medical Center within one to two weeks.
Please follow up with primary cardiologist , Dr. Earnestine Fiermonte
within one month.
OPERATIONS AND PROCEDURES:
None.
OTHER TREATMENTS AND PROCEDURES:
None.
BRIEF RESUME OF HOSPITAL COURSE:
CHIEF COMPLAINT:
Shortness of breath.
HISTORY OF PRESENT ILLNESS:
A 73-year-old man with a history of coronary artery disease
status post coronary artery bypass graft , ischemic
cardiomyopathy , valvular heart disease , known EF of 15-20% as of
9/19 , was admitted to the Pagham University Of from
Sollic Fredlaer Rehabilitation Hospital Of with signs and symptoms of
decompensated heart failure , and acute on chronic renal failure.
On 8/7/06 , he was admitted with a large left foot toe ulcer
that was nonhealing. Multiple surgeries were performed with
persistent nonhealing wounds: Left great toe amputation on
2/18/06 , which failed to heal despite SFA to perineal artery
bypassing the composite vein. Had a short CICU stay for
hypotension postoperatively , maintained on dobutamine. On
7/25/06 underwent debridement of left medial ulcer. On 10/7/06
transmetatarsal amputation , on 11/22/06 , debridement of
transmetatarsal amputation. On 9/22/06 received a left below
the knee amputation. His renal function had been normal prior to
the final surgery until 5/29/06 to 8/13/06 when his creatinine
rose from 1.3 to 2.2. He was discharged to acute rehabilitation
and was there noted to have this acute renal failure , which was
thought to be due to prerenal azotemia , but his creatinine at
this point had not changed much from 2.2 to 2.5 during his stay.
Diuretics were held at rehabilitation facility until two days
prior to admission. He was noted to have increased shortness of
breath. Patient denies any other symptoms up to that point
except occasional lightheadedness , depressed mood , and lack of
motivation. No orthopnea , uses 1 pillow regularly , denies
paroxysmal nocturnal dyspnea , and denies dyspnea on exertion , but
very limited movement.
PAST MEDICAL HISTORY:
Significant for hypertension , GERD , hypercholesterolemia , CAD
status post MI in 1996 , received a CABG in 5/12 with a LIMA to
LAD , SVG to PDA , SVG to OM1 , and mitral valve annuloplasty.
Diabetes mellitus , insulin-dependent , status post bilateral below
the knee amputation , likely from diabetes related foot ulcers ,
history of atrial fibrillation and atrial flutter , history of
sick sinus syndrome , history of second-degree heart block , AICD
placed 10/27 complicated by hematoma. History of admissions for
hyponatremia. Status post left SFA to perineal artery bypass to
incompetent pain in 10/14 .
MEDICATIONS ON ADMISSION:
Amiodarone 200 mg orally daily. Atrovent one to two puffs inhaled
four times a day as needed for wheezing , Celexa 20 mg orally daily , Coumadin 2.5
mg orally daily , Diovan 80 mg orally daily , enteric-coated aspirin
325 mg orally daily , Lantus 25 units every day subcutaneous , Lasix
160 mg orally twice a day , Lipitor 20 mg orally every bedtime , Lopressor 50 mg
orally twice a day , therapeutic multivitamin one tablet orally daily ,
solsite topical.
IMPRESSION:
On admission , a 73-year-old male with severe cardiomyopathy and
ejection fraction of 15% admitted for decompensated heart failure
in the setting of his diuretics being held due to an acute renal
failure. Review of chart at the time of admission showed renal
failure is actually present since the perioperative period of his
BKA. After being admitted to the cardiology service , he was
diuresed successfully to his dry weight , with a significant
improvement in his oxygen saturation , his creatinine , and venous
congestion.
Other active issues he was treated for include urinary tract
infection , diabetes mellitus , acute on chronic renal failure ,
depression.
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular: Ischemia: Known coronary artery disease
status post CABG x3 , admitted with troponin elevation likely due
to demand in the setting of heart failure for having his
diuretics held. This was noted to trend down post-diuresis. We
continued aspirin. Initially , we held his ACE inhibitor given
history of cough and his ARF , and ultimately restarted the
patient on ARB , after his creatinine had normalized. Statins had
been held until we were certain his liver function tests were
decreasing.
2. Cardiovascular pump: The patient remained in floor volume
overload on presentation , maintained on 2 grams salt daily , 2
liters fluid restriction diet with 1-2 liters per day goal
diuresis attained by using 100 mg intravenous torsemide twice a day with the
addition of 25 mg of hydrochlorothiazide twice a day 30 minutes prior
to each torsemide dose , an average of two liter fluid negative.
Diuresis was affected over the course of a week , and his status
gradually improved. Spironolactone was initially held due to
high K but was re-added on 7/20/06 .  His jugular venous
distention dropped from initial presentation above the earlobes
at a 30-degree angle to a JVP of 6-7 cm at 30 degree angle on the
day of discharge. Two days prior to discharge , his creatinine
began to rise , suggesting prerenal azotemia secondary to over
diuresis and when his torsemide was reduced to 100 mg orally daily ,
hydrochlorothiazide was dropped from his regimen , patient's
creatinine began to drop again , and patient was able to maintain
even Ins and Outs of fluid for two days prior to discharge.
3. Cardiovascular rhythm: Patient is ventricularly paced on
symmetry for duration of hospitalization , history of atrial
fibrillation on Coumadin , was maintained on amiodarone during
this hospitalization.
4. Pulmonary: The patient with initial O2 dependence.
Continued inhaled ipratropium his home medication. After
diuresis , the patient was able to achieve oxygen saturation of
100% on room air.
5. Renal: Initial acute on chronic renal failure thought
secondary to volume overload and forward flow in the context of
decompensated congestive heart failure. His renal function
improved , as he was diuresed and his heart likely moved to more
useful part of the starling curve. Renal ultrasound was negative
for hydronephrosis as was test for urine eosinophils.
Hyponatremia was likely due to heart failure improved with
diuresis.
6. Heme: The patient maintained on Coumadin with an INR goal of
2-3. In order to achieve this goal , his Coumadin dose was
adjusted to mg orally every other day. He will be followed by
chemo and Coumadin service after discharge with weekly tests to
make sure that his INR is maintained within this range.
7. Endocrine. Diabetes mellitus , insulin-dependent , covered on
NPH every day before noon and every afternoon with aspartate sliding scale for duration
of hospitalization.
8. Psych: The patient was restarted on Celexa per primary care physician for
likely depressive mood response to recent bilateral knee
amputation. It is what is quite possible that patient's
depression precedes the bilateral knee amputation and informs
much of his overall care. The patient's primary care physician , Dr. Lizabeth D Warpool , aware of the situation and managing as outpatient. The
patient was also seen by the inpatient psychiatry consultation ,
and started on Remeron 7.5 mg orally daily in place of Celexa. He
is discharged on this medication. The patient is status post one
fall from the bed during the hospitalization. Head CT at that
time showed no evidence of bleed or trauma to the head to head.
Examination of back and extremities reveals no focal tenderness
or ecchymoses.
9. Infectious disease. The patient initially treated for
urinary tract infection with uncomplicated course with
ciprofloxacin.
10. Wound: Wound care nurse consulted for BKA wound and small
decubitus on his back , was treated with DuoDERM , BKA site healing
well.
11. Fluids , electrolytes and nutrition: The patient remained on
cardiac , 2000 calorie diabetic diet , however , as it became
apparent that he was severely malnourished , his diet was
liberalized to allow for nutritional supplementation.
12. PPX: The patient maintained on subcutaneous heparin and
Nexium as DVT and GI prophylaxis during this hospitalization.
13. Code status , full code.
TO DO PLAN
1. Discharge the patient to rehab on current regimen. Patient
has been working with physical therapy and OT during this hospitalization and
appears well positioned to take advantage of rehabilitation
facilities services.
2. Maintain new prescription of Remeron , follow up with
psychiatry to assess depressive disorder/adjustment disorder.
3. The patient has been off beta-blocker. primary care physician may choose to
start beta-blocker at a low-dose in the outpatient setting.
4. Fasciculations noted during hospitalization fine
fasciculations at hands in Niland Rawee Hospital .  Maybe secondary to
malnutrition and diaries is , but may merit further workup in an
outpatient context.
5. The patient had rising alkaline phosphatase during
hospitalization , CT of chest incidentally showed gallstone
present within the gallbladder , follow up LFTs in the outpatient
context and possible right upper quadrant ultrasound may merit
consideration and further outpatient workup of this patient. The
patient will follow up with Coumadin clinic given goal INR of
2.0-3.0. The patient's creatinine and BUN should be checked
along with electrolytes to make sure patient is doing well on
current maintenance diuretic schedule of 100 mg torsemide orally
daily and spironolactone.
CODE STATUS:
Full code.
DISCHARGE CONDITION:
Stable. Discharged to rehabilitation.
eScription document: 8-9441840 EMSSten Tel
CC: Earnestine M. Fiermonte M.D.
Ing Sa
CC: Lizabeth Warpool M.D.
KERNAN TO DAUTEDI UNIVERSITY OF OF
Ia Blvd.
Dictated By: DIVELBISS , LONNY
Attending: KATCSMORAK , CARRI
Dictation ID 0953106
D: 6/16/06
T: 6/16/06

Document id: 19

205298095 | PUO | 95928029 | | 638754 | 10/21/1995 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 8/7/1995 Report Status: Signed

Discharge Date: 10/15/1995
PRINCIPAL DIAGNOSIS: MYOCARDIAL INFARCTION.
LIST OF SIGNIFICANT PROBLEMS: DIABETES.
HISTORY OF PRESENT ILLNESS: The patient is a 54 year old , white
male with cardiac risk factors of
diabetes , borderline hypertension , male gender , and a positive
family history , who has no prior cardiac history , but now presents
to A Salt Medical Center complaining of substernal chest
pain. Approximately six weeks ago , the patient lifted a 100-pound
bag and the next a.m. , noted substernal chest pressure without
associated symptoms. This pressure lasted approximately three to
five minutes and resolved spontaneously. Since then , the patient
has had two similar episodes of substernal chest pressure that have
occurred while he was exerting himself , once while running during a
basketball game and once again while running on the beach in
Ing Lum Sey Neither episode had associated symptoms ( i.e. , radiation ,
nausea , vomiting , diaphoresis , palpitations ) , and both episodes
lasted less than five minutes and resolved with rest. On the night
prior to admission , the patient was working regripping his golf
clubs and noted a pulling sensation into his chest , which again
resolved with rest. On the morning of admission , the patient awoke
at 4:00 a.m. , noting a 6-7/10 substernal chest pressure associated
with diaphoresis. The pain persisted for five hours , at which time
the patient presented to CHH .  At CHH , the patient was found to
have a blood pressure of 152/88 and a heart rate of 76. His
physical examination was benign. However , the patient's
electrocardiogram showed new ST depressions in V2-V5 , T wave
inversions in AVL , and flat T's in 1 and V6. The patient was
treated with two sublingual nitroglycerins and sent to the Pagham University Of .  On route to Petersram Medical Center , the patient received
two sublingual nitroglycerin sprays. On arrival , the patient's
pain had dwindled to 1/10 , without associated symptoms. The
patient's blood pressure was 126/80 , with a heart rate of 80. The
patient was treated with an aspirin , a sublingual nitroglycerin ,
nitro paste , Lopressor 5 mg x 1 intravenously , and intravenous
heparin. Upon transfer to the CCU , the patient was pain free. A
repeat electrocardiogram demonstrated resolution of ST depressions
and flat T waves , but persistence of the T wave inversion in AVL.
The patient was admitted for further treatment and to rule out
myocardial infarction. The patient gives no history of edema ,
paroxysmal nocturnal dyspnea , or orthopnea. The patient denies
fevers , upper respiratory infection symptoms , cough , abdominal
pain , nausea , vomiting , diarrhea , dysuria , or weight loss.
PAST MEDICAL HISTORY: The patient's past medical history is
significant for diabetes. The patient has
kidney stones , is status post procedure three to four years ago ,
and a history of sinusitis.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: The patient's medications at the time of
admission included only Glyburide 2.5 mg
orally every day
SOCIAL HISTORY: The patient is unmarried. He was the part owner
of a bar. He does not smoke , and he does not
drink.
FAMILY HISTORY: The patient's mother had a myocardial infarction
in her 60's.
PHYSICAL EXAMINATION: The patient is a pleasant , tan male in no
acute distress. Blood pressure , 126/80.
Heart rate , 80. Respiratory rate , 20. Temperature , 98. Oxygen
saturation , 100% on two liters. Head , eyes , ears , nose , and throat
examination was anicteric , with oropharynx benign. Neck was
supple , with no lymphadenopathy. Carotids were 2+ , with no bruits.
Lungs were clear to auscultation bilaterally. Back examination
demonstrated no costovertebral angle tenderness and no spinal
tenderness. Coronary examination revealed a regular rate and
rhythm , distant S1 and S2 , and no murmurs , rubs or gallops.
Abdominal examination was benign. Rectal examination showed guaiac
negative stool. Extremities showed no cyanosis , clubbing , or
edema , with pulses 2+ throughout , and no femoral bruits.
Neurologic examination revealed the patient to be alert and
oriented x 3.
LABORATORY DATA: Laboratory studies on admission revealed the
patient's electrolytes to be within normal
limits , except for a glucose of 293. The first CK returned 970 ,
with an MB fraction of 65.1. Magnesium was 1.6. CBC was within
normal limits , with a hematocrit of 44.1. Coag's were also normal
at 12.7 and 27.4. Chest x-ray showed no enlarged heart and no
infiltrate. Electrocardiogram showed normal sinus rhythm , with a
rate of 60 , and no ST-T changes on the 15 of August , 1995.
However , electrocardiogram at the Kernan To Dautedi University Of Of , pain free , showed normal
sinus rhythm , with a heart rate of 82 , T wave inversions , AVL , and
flat T's in lead 1.
HOSPITAL COURSE: The patient was admitted with a diagnosis of
acute myocardial infarction. Electrocardiogram
changes were consistent with lateral or anterolateral ischemia.
His peak CK's returned at 1 , 330 , with 54.5% MB fractions. The
patient was maintained on heparin and intravenous nitroglycerin for
72 hours after admission and was started on Lopressor and
enteric-coated aspirin at admission. The patient remained chest
pain free for the five days post myocardial infarction and
underwent a submax ETT on the 5 of August , 1995. In addition , an
electrocardiogram was performed , which showed a left ventricle with
73% ejection fraction , upper limits of normal size , and a question
of inferior wall hypokinesis. On the 24 of June , the patient underwent a
submax ETT , which was stopped secondary to chest tightness , with
diagnostic electrocardiogram changes , maximal heart rate of 96 ,
blood pressure of 145/82 , electrocardiogram with 2 mm ST
depressions , persisting into recovery. Because of a positive ETT ,
the patient subsequently underwent cardiac catheterization , which
showed a proximal left circ lesion 70% stenosed , which was
percutaneous transhepatic coronary angioplastied to 20% residual ,
as well as a mid-left circ lesion 70% stenosed , which was
percutaneous transhepatic coronary angioplastied to a 30% residual.
The left anterior descending was found to be diffusely diseased ,
without focal stenoses , and the proximal right coronary artery
showed a 60% shelf-like lesion. The patient did not experience
chest pain or shortness of breath during the procedure. Post
cardiac catheterization/percutaneous transhepatic coronary
angioplasty , the patient was maintained on his glipizide and
atenolol , 50 mg orally every day , and enteric-coated aspirin , as well as
heparin overnight. Two days after the cardiac catheterization , the
patient underwent a second submax ETT. This he performed without
chest discomfort or electrocardiogram changes.
DISPOSITION: The patient was discharged to home on the 16 of September .
CONDITION ON DISCHARGE: The patient's condition at the time of
discharge was stable.
DISCHARGE PLAN: The patient will receive diabetic teaching as
an outpatient with CHH and will follow up with
Dr. Theiling .
DISCHARGE MEDICATIONS: Atenolol 50 mg orally every day , sublingual
nitroglycerins as needed chest pain , and
Glucotrol 5 mg orally every day
Dictated By: MYRTIS VANTULL , M.D.
Attending: BREE M. THEILING , M.D. GP8  AO528/7048
Batch: 9021 Index No. VDTEQY1WXY D: 10/8/95
T: 6/17/95

Document id: 20

581312753 | PUO | 77634248 | | 5932655 | 3/20/2006 12:00:00 a.m. | CHF exacerbation | | DIS | Admission Date: 3/27/2006 Report Status:

Discharge Date: 4/5/2006
****** FINAL DISCHARGE ORDERS ******
BONING , FREDDA F 207-67-77-5
Mer
Service: CAR
DISCHARGE PATIENT ON: 8/20/06 AT 05:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: KATCSMORAK , CARRI GARY , M.D.
CODE STATUS:
No CPR , No defib , No intubation
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally DAILY
Override Notice: Override added on 10/29/06 by
BOISER , ESTELL J. , M.D.
on order for COUMADIN orally ( ref # 178481090 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: aware
ALLOPURINOL 100 MG orally DAILY
Alert overridden: Override added on 10/29/06 by
BOISER , ESTELL J. , M.D.
SERIOUS INTERACTION: WARFARIN & ALLOPURINOL
Reason for override: aware
TESSALON PERLES ( BENZONATATE ) 100 MG orally three times a day
Number of Doses Required ( approximate ): 20
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally DAILY
FERROUS SULFATE 325 MG orally three times a day Starting Today ( 4/24 )
Food/Drug Interaction Instruction Avoid milk and antacid
GLIPIZIDE 5 MG orally twice a day
K-DUR ( KCL SLOW RELEASE ) 20 MEQ orally twice a day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
LEVOXYL ( LEVOTHYROXINE SODIUM ) 100 MCG orally DAILY
Alert overridden: Override added on 10/29/06 by
BOISER , ESTELL J. , M.D.
SERIOUS INTERACTION: WARFARIN & LEVOTHYROXINE SODIUM
Reason for override: aware
ATIVAN ( LORAZEPAM ) 0.5 MG orally every afternoon as needed Insomnia
TOPROL XL ( METOPROLOL SUCCINATE EXTENDED RELEASE )
100 MG orally DAILY Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
Number of Doses Required ( approximate ): 3
PRAVACHOL ( PRAVASTATIN ) 40 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 10/29/06 by
BOISER , ESTELL J. , M.D.
on order for MULTIVITAMIN THERAPEUTIC orally ( ref #
018429467 )
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
NIACIN , VIT. B-3 Reason for override: aware
Previous override information:
Override added on 10/29/06 by BOISER , ESTELL J. , M.D.
on order for COUMADIN orally ( ref # 178481090 )
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
WARFARIN Reason for override: aware
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Alert overridden: Override added on 10/29/06 by
BOISER , ESTELL J. , M.D.
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
NIACIN , VIT. B-3 Reason for override: aware
TORSEMIDE 80 MG orally twice a day Starting Today ( 4/24 )
COUMADIN ( WARFARIN SODIUM ) 1 MG orally every afternoon
Starting NOW ( 4/24 )
Instructions: WITHIN HOUR OF PHARMACY APPROVAL
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Override Notice: Override added on 10/29/06 by
BOISER , ESTELL J. , M.D.
on order for ALLOPURINOL orally ( ref # 676820163 )
SERIOUS INTERACTION: WARFARIN & ALLOPURINOL
Reason for override: aware Previous override information:
Override added on 10/29/06 by BOISER , ESTELL J. , M.D.
on order for LEVOXYL orally ( ref # 634337691 )
SERIOUS INTERACTION: WARFARIN & LEVOTHYROXINE SODIUM
Reason for override: aware Previous override information:
Override added on 10/29/06 by BOISER , ESTELL J. , M.D.
on order for LEVOFLOXACIN orally ( ref # 675949597 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & LEVOFLOXACIN
POTENTIALLY SERIOUS INTERACTION: WARFARIN & LEVOFLOXACIN
Reason for override: aware Previous override information:
Override added on 10/29/06 by BOISER , ESTELL J. , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: PRAVASTATIN SODIUM &
WARFARIN Reason for override: aware
DIET: Patient should measure weight daily
DIET: House / Low chol/low sat. fat
DIET: House / ADA 1800 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Coletta Verry 8/3/06 @ 11AM scheduled ,
Cardiology clinic for blood work ( Nessinee Ker Hospital Medical Center ) 11/1/06 ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
CHF exacerbation
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
CHF exacerbation
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
congestive heart failure , coronary artery disease , hypertension , diabetes
mellitus , gastroesophageal reflux disease , hypothyroidism , mitral
regurgitation history of repair , lung ca history of lobectomy , endometrial ca history of
TAH/BSO , basal cell carcinoma , chronic renal dysfunction , renal artery
stenosis history of L stent , recurrent flash pulm edema
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
intravenous diuretics , electrolyte monitoring , antibiotics
BRIEF RESUME OF HOSPITAL COURSE:
CC: increasing SOB , weight gain
*****
HPI: patient is a 75F with a history of CHF/CAD , a-fib , lung CA history of R wedge
resection. She has been admitted 5-6 times this year for CHF
exacerbation. She was discharged from the hospital on 3/4 after tx
for CHF and PNA and was followed by the CHF RN. Over the past 3 days
since discharge , she has noticed a 3lb weight gain. Additionally , patient
has had increasing SOB , poor sleep. Stable 2 pillow orthopnea but
more comfortable sitting bent over at the waist. Per her primary care physician's
instructions , patient increased Torsemide to 40mg twice a day which did not
increase her UOP.
ROS: +SOB +PND +orthopnea + bilat LE swelling , brief CP , + diarrhea
( 2 per day ) , no palpitations/dizziness.
*****
In ED: T95.6 P74 BP118/65 RR10 SaO2 on 98 on RA patient received 40 Lasix intravenous.
***
Home Medications: 1. ASA 325 , Allopurinol 100 , Nexium 20 , Iron 325 MG
three times a day Glipizide 5 MG twice a day , K-dur 20 twice a day , Levoxyl 100 MCG , Lorazepam 0.5 MG
every day as needed , Toprol Xl 100 MG , MVI , pravastatin 40 mg every bedtime , Torsemide 40 MG
twice a day , Coumadin 1 MG
***
Allergies: NKDA
****
PMH: CRI , hypothyroidism , paroxysmal a-fib , DM , CHF , CAD , lung CA history of
R wedge resection , basal cell CA on lip history of resection , uterine CA s/pTAH.
***
FHx: non contrib
***
Social: Lives with husband across street from KAAH .  +tob history ,
-EtOH , -IVDU
***
PE on admit: VS:T: 95.6 P74 BP:118/75 RR10 SaO2 100% on RA , JVP
15cm C/V irreg irreg , no m/g/r. Lungs crackles at R base. Legs
2+ LE edema. +tenderness on L shin/bruise , AAOx3 CXR: no pulm edema ,
improved RLL PNA
****
PE on Discharge - 97.7 P65-84 BP 90-108/50 RR18 93-97% on RA , A&OX3 , more
solid stool , lungs CTA on left , decreased breath sounds on right , JVP
8cm , CV irreg irreg , 1+ lower extremity edema on R , 3+ on LLE
****
Studies: LENI 4/30 - negative for DVT in left lower extremity
C Diff negative
****
Hospital Course: 75F with history of CAD/CHF/lung CA/Afib with 3 days of weight
gain , worsening SOB and orthopnea.
1 )CHF: Patient presented with symptoms of heart failure--PND , elevated
JVP and bilateral LE edema. No clinic evidence of acute coronary
syndrome. She was continued on her CAD regimen of BB , asa , statin. She
was diuresed , initially with lasix 40mg intravenous then 80mg intravenous with excellent
results-->1L negative per day on a twice a day regimen. However , her weight
remained unchanged at 165lb. At time of discharge , she is continuing to
be net negative on orally torsemide. She is discharged with torsemide 80mg
twice a day and will have close VNA and electrolyte follow-up. Dry weight
goal previously had been 155-157lb , but given the resolution in her
symptoms and overall clinical picture , she is discharged above her dry
weight with close follow-up.
2 ) Afib --continue coumadin 1mg , INR on discharge is 2.1
3 ) PNA- Recent RLL PNA for which she completed course of levofloxacin and
cefpodoxime. Diarrhea likely antibiotic associated , was negative for C
diff and responded to lactobacillus supplements.
4 ) Anemia: Chronic iron deficiency. HCT 28.7 but elected not to
transfuse. Continue iron supplement.
5 ) FEN- patient was compliant with a 1.5L fluid restriction and <2g salt
cardiac diabetic diet.
6 ) Diabetes - Was managed on lantus/novolog in house and will resume
orally DM meds on discharge. Continued Levoxyl 100meq. Recent TSH 8/22
wnl. Continue allopurinol for presumed gout.
ADDITIONAL COMMENTS: During this hospitalization you were treated for heart failure. You
should continue to monitor your diet and salt intake. We have increased
your diuretic dose to torsemide 80mg twice a day. Please have your blood
electrolytes checked in 2 days. If you have any chest pain , worsening
shortness of breath , or any other concerning symptom call your doctor or
go to the ER.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. VNA services for cardiopulmonary assessment , weight monitoring , heart
failure monitoring
2. She is discharged on torsemide 80 twice a day and will need her electrolytes
checked in 2 days.
3. Coumadin followed by Dr. Pidro with Flanda Medwan Rorael Memorial Hospital And Health Services
No dictated summary
ENTERED BY: BONEFONT , KEIRA B. , M.D. , PH.D. ( TK84 ) 8/20/06 @ 02:43 PM
****** END OF DISCHARGE ORDERS ******

Document id: 21

506204373 | PUO | 74372820 | | 0168083 | 5/4/2005 12:00:00 a.m. | CORONARY ARTERY DISEASE | Signed | DIS | Admission Date: 9/10/2005 Report Status: Signed

Discharge Date: 10/2/2005
ATTENDING: PETTINGER , DOUGLASS MD
PRIMARY DIAGNOSES:
1. Atrial fibrillation with RVR.
2. Congestive heart failure.
3. Sick sinus syndrome.
4. Delirium.
OTHER DIAGNOSES:
1. Diabetes , newly diagnosed.
2. Chronic anticoagulation.
3. Hypertension.
4. History of GI bleed.
5. Prior CVA.
HISTORY OF PRESENT ILLNESS:
Mr. Burrs is an 89-year-old male with a history of multiple
medication problems , including hypertension , atrial fibrillation ,
sick sinus syndrome , history of colon cancer and prostate cancer ,
status post embolic stroke in 3/22 , and history of congestive
heart failure with an EF of 40-50% , who presented to the
emergency room complaining of two days of increased lethargy. At
that time , he denied cough , chest pain , shortness of breath , PND
or orthopnea. In the emergency room , the patient was found to
have a heart rate in the 120s with a new left bundle-branch
block. Carotid massage was attempted and the patient blocked to
15:1 due to sick sinus syndrome. An echocardiogram was done in
the emergency room , which revealed an EF of 25%. It was felt
that the patient was in acute congestive heart failure
exacerbation secondary to the atrial fibrillation with RVR. It
was deemed at that time too dangerous to pharmacologically
convert the patient. He was transferred to the Coronary Care
Unit for placement of a transvenous pacer.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Arthritis.
3. Atrial fibrillation , on anticoagulation.
4. History of prostate cancer , status post prostatectomy.
5. History of colon cancer , status post partial colectomy.
6. History of dementia.
7. History of GI bleed.
8. Status post MRSA wound infection.
9. Status post embolic CVA in 6/17/05 .
10. Sick sinus syndrome.
HOME MEDICATIONS:
1. Colace.
2. Coumadin.
3. Folate.
4. Synthroid 25 mcg daily.
5. Toprol 50 mg orally twice a day
6. Protonix.
7. Zyprexa.
8. Aspirin.
ALLERGIES:
No known allergies.
SOCIAL HISTORY:
The patient denies cigarette , drug or alcohol use.
FAMILY HISTORY:
The patient had a father who died at the age of 63 of a heart
attack. There is a family history of colon cancer.
PHYSICAL EXAMINATION ON ADMISSION:
Afebrile , pulse irregular , 125; blood pressure 140/100. Pulse
oximetry was 97% on 2 liters. General: This is an elderly male
in no acute distress. Neck: Supple , no lymphadenopathy , no
thyroid enlargement , JVP at 18 cm with flutter waves. Carotids
are 2+ bilaterally. Pulmonary: Bibasilar rales.
Cardiovascular: Irregular rate and rhythm , tachycardic , S1 , S2
normal. No murmurs , rubs or gallops. Abdomen: Soft , nontender
and nondistended. Bowel sounds are present. Extremities: Warm
bilaterally , 2+ pitting lower extremity edema. No clubbing or
cyanosis.
LABORATORY STUDIES UPON ADMISSION:
Notable for mild elevation of the white blood cell count of 11.0 ,
hematocrit of 40.6 , and platelets of 218 , 000. Electrolytes were
within normal limits. The creatinine was mildly elevated at 1.3.
BNP was markedly elevated at 7931. Coagulation showed an INR of
2.9. LFTs were within normal limits. Cardiac enzymes showed a
CK of 129 , CK-MB of 5.9 , and an elevated troponin at 0.27. EKG:
Atrial flutter with RVR , rate in the 120s , and new left
bundle-branch block. Chest x-ray: Cardiomegaly and
cephalization , no acute infiltrate.
ASSESSMENT AND PLAN UPON ADMISSION:
This is an 89-year-old male with a history of sick sinus
syndrome , atrial fibrillation , on Coumadin , as well as congestive
heart failure , who was admitted for atrial fibrillation/atrial
flutter with RVR , and decompensated congestive heart failure. At
the time of admission , the patient was felt to be at risk
secondary to his sick sinus syndrome and new left bundle-branch
block. He was felt to be at risk for asystole and symptomatic
bradycardia with any blocking agents. Therefore , transvenous
pacer was scheduled to be placed in the Cath Lab.
HOSPITAL COURSE BY SYSTEM:
1. Cardiovascular:
a. Rhythm: Shortly after admission , the patient had a temporary
ventricular pacer placed on 9/13/05 with a heart rate of less
than 50. After the procedure , the patient was admitted to the
CCU with atrial flutter with RVR and a rate in the 20s. The rate
was intermittently controlled with a combination of intravenous digoxin
and Lopressor. On 6/6/05 , a permanent dual-chamber pacemaker
was implanted with VVI at 50. Throughout the next two days , the
patient's heart rate continued to be difficult to control , but
improved with diltiazem. The patient was initiated on an
amiodarone load on 8/22/05 .  The following day , he converted to
normal sinus rhythm spontaneously. At that time , he continued to
be ventricularly paced , and the pacemaker was changed to DDD on
10/21/05 .  For the remainder of the hospitalization , the patient
remained in normal sinus rhythm and was dual-paced without any
recurrence of arrhythmias. He will be continued on his
amiodarone load , which was 2.9 g upon discharge and we continued
for a total load of 10 g.
b. Pump: Upon admission , an echocardiogram on 5/23/05 showed
an EF of 20-25% with regional wall motion abnormalities noted in
the intraventricular septum , which was akinetic as well as global
hyperkinesis of the left ventricle. On admission , the patient
had indications of heart failure , including increased JVP and
bilateral lower extremity edema , as well as pulmonary effusions.
The patient was diuresed effectively with low-dose intravenous Lasix. His
admission weight was 91 kg , and upon discharge , it was
approximately 87 kg. The patient was given intermittent Lasix 10
mg intravenous for diuresis to maintain a negative I&O of 500 mL. Upon
discharge , the patient may require continued diuresis with home
regimen of orally Lasix. In addition , the patient was noted to
have marked hypertension throughout his stay. Blood pressure was
occasionally difficulty to control , and at times , required intravenous
nitro drip. Systolic blood pressures were noted to as high as
180 and as low as 100 with intravenous nitro drip. The patient's blood
pressure was managed with calcium channel blocker , beta-blocker ,
as well as ACE inhibitor. Upon transfer to the cardiology floor
on 10/21/05 , the orally diltiazem was increased. Upon discharge ,
the patient will be continued on a home regimen of lisinopril 10
mg orally daily , Toprol-XL 100 mg orally twice a day , and diltiazem
extended release 360 mg orally daily. At the time of discharge ,
the patient's blood pressure was well controlled with systolic
blood pressures ranging from 110 to 120s.
c. Ischemia: Upon admission , the patient had cardiac enzyme
elevation with initially 0.27 , which elevated to a max of 1.27 on
10/23/05 .  Initially , the enzyme elevations were thought to be
secondary to demand ischemia in the setting of an elevated heart
rate and volume overload. However , the patient underwent a
cardiac catheterization on 2/25/05 which showed evidence of
coronary artery disease , two-vessel disease , specifically , there
was a LAD proximal 90% lesion as well as diffuse proximal-mid
standing 80% lesion , as well as RTLV-BR mid discrete 80% lesion
beyond the bifurcation of RPDA. On 2/25/05 , the patient had a
successful roto-ablation , angioplasty , and insertion of three
cipher DES to the LAD resulting in TIMI 2 flow. On 1/1/05 , the
patient returned to the cath lab , and at that time , he had a DES
placement at distal RCA. The patient denied a chest pain
throughout his stay. Upon discharge , he was able to ambulate
without significant dyspnea on exertion or chest discomfort.
2. Psychiatry: At the beginning of the hospital stay , the
patient was confused and somewhat agitated. His behavior was
controlled with Haldol as well as as needed Ativan. The patient's
confusion and delirium improved significantly , and the Haldol and
Ativan were tapered off. Prior to discharge , he was reinitiated
on his home regimen of Zyprexa. The patient has a longstanding
history of dementia. Geriatrics consult followed in this case
and advised on titration of a Haldol.
3. Vascular: Following the cardiac catheterization , the patient
was noted to have a right femoral bruit. A vacular ultrasound
was obtained on 7/18/05 and did not show any evidence of an AV
fistula.
4. Heme: The patient is on chronic anticoagulation for atrial
fibrillation. Upon admission , his INR was 2.9 and became
elevated to a supratherapeutic level. Therefore , his Coumadin
was held. The patient will be reinitiated on Coumadin when his
INR is below 2. Goal INR will be between 2 and 3.
5. Endocrine: The patient has a history of hypothyroidism and
was continued on his home dose of Synthroid 25 mcg orally daily.
Thyroid function tests were checked and were within normal
limits. In addition , the patient was noted to have mildly
elevated fasting blood glucoses during his admission. His blood
sugars ranged from 95 to 182. He was maintained on a regular
sliding scale insulin and required only minimal units of
supplemental insulin. A hemoglobin A1c was ordered , and the
results are still pending at this time.
6. GI: The patient was noted to have significant constipation
throughout his stay and was continued on an aggressive bowel
regimen , which included Colace , senna , lactulose , and Dulcolax.
The patient has a history of GI bleed. He was noted to have a
small amount of blood in the stools secondary to constipation ,
but this was resolved with additional bowel movements. His
hematocrit remained stable , with no signs of anemia. The patient
does have a history of colon cancer for which he underwent a
colectomy. He will be followed as an outpatient.
7. FEN: Due to the patient's heart failure , he was placed on a
2-liter fluid restriction as well as 2 g salt restriction. The
patient was continued on a low-cholesterol , low-salt diet. Due
to his mild sedation with Haldol , the patient was evaluated by
speech and swallow and initially placed on mechanical soft diet
with some honey-thick liquids. As his mental status improved
significantly , the patient was returned to a house diet ,
low-cholesterol , low-fat , with the previous salt and fluid
restrictions. The patient was continued on light scale
throughout his stay.
8. ID: The patient was noted to have a urinary tract infection
based on urinalysis upon admission. His culture remained
negative throughout his stay. He was initially given
ceftriaxone. Initially , he was started on Keflex following on
pacemaker placement for antibiotic coverage , which was
discontinued on 1/12/05 .  The patient remained afebrile , with no
signs of systemic infection throughout his stay.
9. Prophylaxis: The patient was placed on a PPI. His INR
remained subtherapeutic throughout his stay.
COMPLICATIONS:
None.
CONSULTANTS:
EP fellow , Dr. Cabreja attending Dr. Dominguez .
PHYSICAL EXAMINATION UPON DISCHARGE:
General: This is a pleasant elderly female in no acute distress ,
alert and oriented x3. HEENT: Normocephalic and atraumatic.
Extraocular motions are intact. Pupils are equal , round and
reactive to light. Neck: Supple , no lymphadenopathy.
Cardiovascular: Regular rate and rhythm , no murmurs , rubs or
gallops , normal S1 , S2. JVP at 9 cm. Respiratory: Sparse
bibasilar crackles that cleared with cough. Abdomen: Soft ,
nontender and nondistended , bowel sounds present. Extremities:
Trace edema bilaterally , no clubbing or cyanosis. Pedal pulses
are palpable. Neuro: Cranial nerves II-XII are grossly intact.
There will be an addendum to this discharge summary , which will
include discharge medications and follow-up plans.
eScription document: 5-1521769 EMSSten Tel
Dictated By: LAVERGNE , TAMEIKA
Attending: PETTINGER , DOUGLASS
Dictation ID 8276341
D: 7/18/05
T: 7/18/05

Document id: 22

015428741 | PUO | 26040636 | | 315039 | 10/13/1992 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 5/28/1992 Report Status: Signed

Discharge Date: 11/6/1992
ADMISSION DIAGNOSIS: STATUS POST TRANSIENT ISCHEMIC ATTACK
COMPLICATED BY A LONG HISTORY OF VERTIGO.
HISTORY OF PRESENT ILLNESS: Patient was in her usual state of
health until the day of admission when
she had sudden onset of increased vertigo , dizziness , and near
syncope as well as left leg weakness and dysarthria. She had a
mild frontal headache , no palpitations , no chest pain , and no
shortness of breath. These symptoms lasted two to three hours with
slow gradual improvement. She phoned her CHH doctor who referred
her to Pagham University Of .  On admission , she complained
of no residual symptoms. She had no visual changes , no amaurosis ,
no paresthesias or numbness , and was feeling at her baseline. Her
history , of pertinence , in 1988 , she had a syncopal episode. A
Holter at that time revealed some atrial fibrillation and
non-sustained ventricular tachycardia for which she was started on
Atenolol. In 1990 , she had a villous adenoma diagnosed and
underwent an abdominoperineal resection complicated by
post-operative atrial fibrillation. She ruled out for myocardial
infarction at that time. For the past year , she has described
intermittent episodes of dizziness , so called room spinning , and
fatigue lasting for a few minutes occurring only once a month. She
has no other significant past medical history besides hypertension.
ALLERGIES: She has no known drug allergies. She is a non-smoker
and non-drinker. She is a Mexican speaking woman who lives alone
with a number of family members nearby. CURRENT MEDICATIONS: She
was on Atenolol 50 mg every day
PHYSICAL EXAMINATION: She was a pleasant Mexican speaking elderly
woman in no acute distress. Vital signs
showed her to be afebrile , blood pressure 160/80 lying down , 160/80
sitting up , pulse 70 lying down with pulse 76 sitting , and
respiratory rate 16. HEENT: Examination showed normal cranium ,
atraumatic , extraocular movements intact , and pupils equal , round ,
and reactive to light. She had bilateral cataracts detected and
her oropharynx was clear and within normal limits. NECK: She had
no jugular venous distention , neck was supple , she had full range
of motion , and her carotids were 1+ bilaterally with good upstroke.
No bruits were appreciated. LUNGS: Clear bilaterally. No spinal
or costovertebral angle tenderness appreciate. CARDIAC:
Examination showed rate and rhythm were regular , S1 and S2 , an S4
was appreciated , and no S3 with a I/VI systolic ejection murmur.
ABDOMEN: She had a colostomy , her abdomen was soft and non-tender ,
positive bowel sounds , and no masses. EXTREMITIES: No clubbing ,
cyanosis , or edema. No rashes were appreciated. NEUROLOGICAL:
Examination was non-focal. She was alert and oriented times three
and cranial nerves II-XII were within normal limits. Motor
examination showed 5/5 strength with no pronator drift and sensory
examination was grossly within normal limits. Deep tendon reflexes
were 1+ bilaterally and symmetric with downgoing toes and
finger-to-nose was within normal limits.
LABORATORY EXAMINATION: Sodium 140 , potassium 4.1 , chloride 107 ,
bicarbonate 22 , BUN 28 , creatinine 1.2 ,
and glucose 123. Hematocrit was 38.2% , white count 11.2 with a
normal differential , and platelets were 291. physical therapy was 12.9 and PTT
was 24.3. Admission CK was 50. Urinalysis revealed 60-80 white
blood cells , no red blood cells , and 1+ squamous epithelium in the
sediment. Portable chest X-Ray was within normal limits except for
a tortuous aorta and admission EKG showed sinus bradycardia at 58 ,
intervals 0.18/0.09/0.44 , an axis of negative 21 degrees , there was
evidence of left ventricular hypertrophy by voltage criteria , and a
flipped T wave in III which was new compared with an EKG of February
1990. There were no acute ST changes. Head CT on admission
revealed an old lacune in the right internal capsule , some
paraventricular white matter low density changes with evidence of a
lacunar infarct in her right cerebellum which was of indeterminant
age.
HOSPITAL COURSE: The impression on admission was that this was a
75 year old white female with a history of
hypertension and a history of atrial fibrillation , non-sustained ,
who presents with a two to three hour episode of vertigo and left
sided weakness which spontaneously resolved. She was admitted for
further evaluation of this transient ischemic attack thought to be
due either a vertebovascular insufficiency syndrome , anterior
circulation , carotid stenosis , or an embolus from a cardiac source.
Neurology was consulted and , in addition , she was entered on a rule
out protocol for a myocardial infarction. Her abnormal urinalysis
was also of concern despite her lack of symptoms and she was
afebrile. Repeat urinalysis was ordered and urine was sent for
culture and sensitivity. Hospital course over the next few days ,
the patient remained completely asymptomatic except for an
occasional complaint of mild palpitations , occasional vertigo , and
occasional frontal headache. She was started on Coumadin on
hospital day number two for which she entered therapeutic range by
hospital day number four. On hospital day number two , she had a
Holter placed which showed normal sinus rhythm for 24 hours except
for one five-beat run of ventricular tachycardia and two episodes
of atrial fibrillation/flutter , the longest lasting thirteen beats.
On hospital day number two , she had an echocardiogram which showed
concentric left ventricular hypertrophy without evidence of
thrombus or valvular disease. On hospital day number four , she had
a carotid non-invasive study which revealed completely patent
carotid arteries without evidence of stenosis or atherosclerotic
lesions. On hospital day number five , she had a magnetic resonance
imaging of her head with angiogram , the results of which were
pending at the time of discharge. After being hospitalized for
five days , the patient was completely stable in therapeutic range
on Coumadin without focal neurologic findings and without obvious
source of her transient ischemic attack beyond a mild transient
arrhythmia. Therefore , she was discharged with instructions to
follow-up with her regular CHH physician for continued monitoring
of her Coumadin dosing and physical therapy levels as well as long-term
instructions for follow-up care.
DISPOSITION: DISCHARGE MEDICATIONS: Atenolol 50 mg every day and
Coumadin 5 mg every bedtime
BY745/7320
DESIRAE MARCOTT , M.D. RG26 D: 10/10/92
Batch: 5812 Report: U6594M3 T: 3/3/92
Dictated By: DEJA KINTOPP , M.S.
cc: 1. HERMINA T. TUOMALA , M.D.

Document id: 23

171486426 | PUO | 43712082 | | 5442797 | 7/6/2006 12:00:00 a.m. | PNEUMONIA | Unsigned | DIS | Admission Date: 6/2/2006 Report Status: Unsigned

Discharge Date: 3/3/2006
ATTENDING: COCOMAZZI , REA M.D.
SERVICE: ENMH .
DISCHARGE DIAGNOSES:
Pneumonia and UTI.
ASSOCIATED DISCHARGE DIAGNOSES:
1. History of right MCA embolic stroke on 5/15 status post
right ICA on 3/1/06 .
2. History of temporal lobe epilepsy.
3. ADD.
4. Stage III non-small-cell lung cancer status post XRT and
chemo.
5. Hypertension.
6. Asthma.
7. Graves' disease.
8. Depression.
9. History of subclavian steal syndrome.
10. History of urinary tract infection.
HISTORY OF PRESENT ILLNESS:
This is a 63-year-old right-handed lady with history of stage III
non-small-cell lung cancer status post XRT and chemotherapy ,
history of right MCA stroke status post right CEA on 3/1/06 for
70% stenosis of the right ICA , question history of right temporal
lobe epilepsy , who was readmitted to the medicine service from
her nursing home for question of altered mental status , fever ,
and cough. The patient was recently admitted from 2/24/06 to
1/5/06 for change in mental status , treated for presumed UTI
but grew with yeast but no bacteria. The patient was consulted
by neurology for increased somnolence. She had a head CT at that
time that shows encephalomalacia in right MCA distribution
consistent with old stroke with no acute intracranial
hemorrhages , midline shifts , or mass effect. No definite
metastatic lesions were observed. Per patient's oncologist , her
response to treatment has been excellent. She has a negative
EEG. MRI/MRA always shows the right MCA infarct. Normal B12 ,
folate , TSH , and RPR. Neurology at that time agreed that no
further evaluation of somnolence is necessary at this time and
leptomeningeal disease is unlikely given her lack of neurological
finding. The patient was then transferred to rehab on 1/5/06 .
Per nursing and discussion with house staff , the patient has had
waxing and waning mental status and at times appearing alert and
appropriate and other times somewhat hallucinating and agitated.
She also had periods of cough and fever and pain on urination.
According to the son , she has had a cough for the last 10 days
prior to admission. She has not been eating adequately with food
sticking out from her mouth and not quite responsive. She had a
chest x-ray done on 7/26/06 that shows a right hilar mass and
right upper lobe infiltrate. She was started on moxifloxacin 400
mg orally daily on 7/26/06 and then she was transferred here at
Lostedin Nassjoh Valley Hospital at the son's request for change in mental
status , cough , and fever and presumed pneumonia.
In the ED , her temperature was 98.8 , pulse 122 , blood pressure
160/68 , breathing at 20. She got vancomycin , levofloxacin , and 4
L of fluids. Chest x-ray was consistent with right upper lobe
pneumonia , question of postobstructive pneumonia. Her UA was
quite dirty with oxalate crystal , yeast , and 100+ white blood
cells. She was started on vancomycin and levofloxacin for
presumed pneumonia and UTI. Her head CT was negative for any
acute change but also shows chronic right MCA infarct. The
patient was transferred to the floor for further management.
PAST MEDICAL HISTORY:
1. Right MCA embolic CVA 5/15 status post right ICA on
3/1/06 .
2. History of temporal lobe epilepsy followed by Adele Ahlm at
TEVH .
3. ADD.
4. Stage III non-small-cell lung cancer status post XRT and
chemo.
5. Hypertension.
6. Asthma.
7. Graves' disease.
8. Depression.
9. History of subclavian steal syndrome.
10. History of urinary tract infection.
PAST SURGICAL HISTORY:
1. She had bilateral salpingo-oophorectomy 30 years ago.
2. History of radioactive iodine for Graves' disease 30 years
ago.
MEDICATIONS ON ADMISSION:
1. Cymbalta 20 mg twice a day
2. Lamictal 20 mg twice a day
3. Zydis 5 mg twice a day as needed
4. Seroquel 100 mg twice a day as needed
5. Niferex 150 mg twice a day orally
6. Lovenox 40 mg subcutaneously daily.
7. Vitamin B12.
8. Toprol XL 100 mg daily.
9. Zocor 20 mg daily.
10. Prilosec 20 mg orally daily.
11. Lactulose 30 mg orally four times a day as needed constipation.
12. Synthroid 125 mcg orally daily.
13. Ritalin 2.5 mg orally twice a day
14. Compazine 10 mg orally twice a day
15. Lidoderm patch 5% topical.
16. Dilaudid 2 mg orally every afternoon
17. NovoLog sliding scale.
18. APAP 500 mg two tabs twice a day
ALLERGIES:
To intravenous contrast , penicillin for which she has a hive reaction ,
valproic acid and sulfa drugs. Demerol causes hypertension.
SOCIAL HISTORY:
She is divorced , with two children. No alcohol use recently.
100-pack-year history of smoking but quit , occasionally still
asks for cigarettes. The patient feels that she feels better on
nicotine patch.
FAMILY HISTORY:
Father died of MI at 73 , mother died in her 80s of emphysema.
PHYSICAL EXAMINATION:
Vital signs: Temperature 98.8 , pulse 122 , blood pressure 116/68 ,
respiratory rate 20 , O2 saturation 90% on 2 L. She was a
chronically ill-appearing , minimally verbal , responding to
commands. HEENT: PERRL , EOMI , dry mucus membrane , poor
dentition , and no orally lesions. Neck: Supple , no LAD , with
healing incisions on the right. Chest: Rhonchorous crackles
right greater than left. Decreased breath sounds in her right
upper lobe with occasional wheezes. Cardiac: Tachy , regular
rate , normal S1 and S2 , no murmur , rub , or gallop. Abdomen:
Soft , nontender , nondistended , mild tenderness on palpation on
the right quadrant. Extremities: No cyanosis , clubbing , or
edema , 2+ DP pulses , contraction from upper extremity from stroke
bilaterally , worse on the left. Left hand in a brace. Skin: No
rashes , petechiae. Neuro: Oriented x2 , waxing and waning
mental status: Left-sided weakness , 0/5 strength upper
extremity , 1/5 strength lower extremity , 2+ reflexes throughout.
LABORATORY DATA:
Her labs are basically unremarkable. Lytes; her white count is
14.2 , hematocrit 37.6. She does have 2% polyps , 6% bands. LFTs
remarkable only for elevated alkaline phosphatase of 126.
Albumin is 3.4. Her cardiac enzymes are less than assay. Chest
x-ray shows overall unchanged ill-defined right hilar mass and
prior new faint parenchymal opacity in the right upper lobe
concerning to early pneumonia that can be postobstructive. EKG
is tachy , normal sinus rhythm , no ST-T wave changes. Head CT , no
acute change , chronic right MCA infarct. Echo , trace MR , EF
55-60% , known LV function with diastolic dysfunction.
ASSESSMENT AND PLAN:
This is a 64-year-old right-handed woman with history of stage
III non-small-cell lung cancer status post XRT and chemotherapy ,
history of right ICA stroke status post right RCA 3/1/06 ,
recent hospitalization for change in mental status and UTI who
was admitted from nursing home for altered mental status , fever ,
and cough and dysuria. Found to have pyuria with calcium oxalate
crystal , new right upper lobe opacity concerning for
postobstructive pneumonia. Her head CT was unchanged. The
patient was admitted for presumed pneumonia and UTI.
ID: The patient has elevated white blood cell count bandemia in
the setting of right upper lobe opacity concerning for
postobstructive pneumonia and also with pyuria with yeast. The
patient received vancomycin and levofloxacin in the ED. She was
briefly put on vancomycin and levofloxacin and added Flagyl for
aspiration pneumonia. She subsequently also switched over to
vancomycin , Ceptaz , and Flagyl to cover for pseudomonas. Her
urine culture grew out yeast and her blood culture was negative
to date. Her antibiotic regimen was changed back to
levofloxacin , Flagyl on orally regimen. On postoperative day #4 ,
she was improving. She did have one brief episode of
hypertension on hospital day #2 that responded to intravenous fluids. She
has required no escalation in antibiotics and tolerated
levofloxacin and Flagyl quite well. She will continue her
levofloxacin and Flagyl for an additional 14 days. She also got
a chest CT that shows right upper lobe pneumonia and also
question of consolidation in right lung with underlying
emphysema. The consolidation is contiguous with the right hilum
and underlying hilar adenopathy or hilar mass cannot be excluded.
She also has small right pleural effusion. The findings were
discussed with Dr. Enamorado who is her oncologist and he felt that
she is likely having post XRT changes and no further workup is
necessary for now. She will continue to finish her course of
antibiotics of orally levofloxacin and Flagyl for 14 days.
Urology: Her UTI shows yeast. Given that the fact that she has
multiple episodes of yeast UTI currently , she was treated with
fluconazole for three days.
Neuro: She has changes in mental status waxing and waning ,
however , the patient's mental status has greatly improved
throughout her hospital stay although with occasional episode of
hallucinations. For example she was thinking that the resident
is her niece. Psych , onch , and geriatrics was asked to see the
patient at the son's request. Both psy onc and geriatrics
believed that her change in mental status is multifactorial , and
is likely a result of delirium rather than dementia. They
recommended avoiding pain meds and oversedating meds and started
her on zyprexa 5mg twice a day , 2.5mg twice a day as needed agitation , and can increase
to 10mg orally every bedtime if necessary for agitation. She was continued on
her Lamictal and Cymbalta and has no further neurological
decompensation. Her Seroquel was decreased to 50 mg twice a day
as needed and Zydis 5 mg orally as needed , however , she was not receiving
these medications as she was not agitated. She had one dose of
seroquel on 3/11 early am and got really over sedated. Seroquel
was d/c and patient should not be receiving seroquel in the
future for risk of oversedation. Her vitals were stable
throughout.
CV: History of controlled prolonged QTC on Haldol. Her Haldol
was DC'd last admission , is now on Zyprexa and Seroquel. Her
EKGs were stable throughout her hospital stays.
Heme/Onch: The patient has history of stage III non-small-cell
lung cancer status post XRT and chemotherapy and is followed by
her outpatient oncologist , Dr. Rossie Mankoski , at the Setlake Caardlin County Medical Center as well as the outpatient psycho/onch social
worker whose name is Dr. Gaylene Faniel . The patient was seen by
psych/onch and geriatric. Dr. Enamorado stated that she does not
have any further chemotherapy treatment planned for the future.
He will evaluate her when he sees her again in clinic. She is
not currently at the best medical condition to receive any
further therapy.
Endocrine: She was given NovoLog sliding scale for diabetes and
levothyroxine for history of Graves' and history of radioiodine
ablation.
FEN: the patient was seen by speech and swallow for question of
dysphagia and difficulty with swallowing and eating. The
patient's video flow examination shows prolonged orally phase , but
she did well on the rest of her video swallow examination so she
was put on a mince ground diet and thin liquids. Alternate
liquids and solids with tongue sweep to remove orally cavity
residue. The patient recommended to sit upright to take small
bites and sips. She should be seen by speech and swallow for
follow up swallow treatments two to three times per week. She
also was given nutrition consult who started the calorie counts.
Nutrition recommended that she may be need long-term nutritional
therapy if she does not meet her nutritional goal. That will be
deferred to her outpatient doctors at a later time. She will
need assists and encouragement with feeding. She was also given
Nexium for prophylaxis and replete her lytes with an American
Diabetic Diet with low salt. She was given Lovenox and PPI for
prophylaxis.
CODE: Full code.
The patient is discharged to rehab in stable condition.
DISCHARGE MEDICATIONS:
1. Tylenol 650 mg orally every 4 hours as needed headache.
2. Albuterol inhaler two puffs inhaler every 6 hours as needed shortness of
breath or wheezing.
3. Aspirin 81 mg orally daily.
4. Dulcolax 5-10 mg orally daily as needed constipation.
5. Vitamin B12 50 mcg orally daily.
6. Colace 100 mg orally twice a day
7. Dilaudid 1-2 mg orally every 12 hours as needed pain.
8. Ibuprofen 600 mg orally every 6 hours as needed pain and temperature.
9. Lactulose 30 mL orally four times a day as needed constipation.
10. Synthroid 125 mcg orally daily.
11. Ritalin 2.5 mg orally twice a day
12. Toprol XL 100 mg orally daily.
13. Flagyl 500 mg orally three times a day x14 days.
14. Niferex 150 mg orally twice a day
15. Senna two tabs orally twice a day
16. Zocor 20 mg orally every bedtime
17. Neurontin 100 mg orally twice a day
18. Compazine 5-10 mg orally every 6 hours as needed nausea.
19. Lovenox 20 mg subcutaneously daily.
20. Lamictal 200 mg orally twice a day
21. Levofloxacin 500 mg orally daily x14 days.
22. Seroquel 50 mg orally twice a day as needed insomnia and anxiety.
23. Nexium 20 mg orally daily.
24. Combivent neb every 6 hours as needed shortness of breath.
25. Zydis 5 mg orally twice a day as needed anxiety.
26. Lidoderm 5% patch topical daily.
27. NovoLog sliding scale before every meal and every bedtime
28. Cymbalta 20 mg orally twice a day
DISPOSITION:
The patient is to be discharged to rehab. She will follow up
with her primary care physician and Dr. Enamorado .
eScription document: 5-7990038 EMSSten Tel
CC: Rea Cocomazzi M.D.
Dictated By: STRAHL , ROSAURA
Attending: COCOMAZZI , REA
Dictation ID 9464454
D: 9/24/06
T: 9/24/06

Document id: 24

000012052 | PUO | 18541153 | | 8135304 | 4/2/2005 12:00:00 a.m. | UTI | | DIS | Admission Date: 4/10/2005 Report Status:

Discharge Date: 9/6/2005
****** FINAL DISCHARGE ORDERS ******
BACHMAN , LEONIE K. 390-11-18-0
Vallridale Na Ho
Service: MED
DISCHARGE PATIENT ON: 2/25/05 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: VAJDA , FRANCISCO M. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ELAVIL ( AMITRIPTYLINE HCL ) 25 MG orally every bedtime
Override Notice: Override added on 10/30/05 by
BUECKERS , CLEMENTINA O. , M.D.
on order for LEVOFLOXACIN intravenous ( ref # 79785165 )
POTENTIALLY SERIOUS INTERACTION: AMITRIPTYLINE HCL &
LEVOFLOXACIN Reason for override: aware
ATENOLOL 100 MG orally every day
CIPROFLOXACIN 250 MG orally every 12 hours
Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
FLUOXETINE HCL 20 MG orally every day
GEMFIBROZIL 600 MG orally twice a day
Alert overridden: Override added on 10/30/05 by
BUECKERS , CLEMENTINA O. , M.D.
SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
Reason for override: aware
LORAZEPAM 1 MG orally every day as needed Anxiety
SIMVASTATIN 40 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 10/30/05 by
BUECKERS , CLEMENTINA O. , M.D.
on order for GEMFIBROZIL orally ( ref # 10026063 )
SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & GEMFIBROZIL
Reason for override: aware
AMLODIPINE 10 MG orally every day Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
VICODIN ( HYDROCODONE 5 MG + APAP ) 1-2 TAB orally every 6 hours
Starting Today ( 9/2 ) as needed Pain
IRBESARTAN 300 MG orally every day
Number of Doses Required ( approximate ): 10
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Please follow-up with primary care physician at your previously scheduled appointment. 6/6/05 ,
ALLERGY: ORPHENADRINE CITRATE ,
ANGIOTENSIN CONVERTING ENZYME INHIBITOR
ADMIT DIAGNOSIS:
UTI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
UTI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
?CARDIOMYOPATHY EF=39%( 1989 HTN
SEVERE HYPERCHOL/HYPER TG POORLY CONTROLLED DM history of
CHOLE/APPY/TAH DIFFUSE ABDOMINAL PAIN ELEVATED
LIPASE ALLG: SULFA/AMOXICILLIN
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Labs , Antibiotis , CXR , EKG , Telemetry
BRIEF RESUME OF HOSPITAL COURSE:
CC: n/v/diarrhea
HPI: 66 y'o woman with a hx of HTN , DM , Hypercholesterolemia , known CAD
USOH until 3 wks ago when she developed vague abd discomfort. The
abd discomfort progressed and three days ago she developed acute onset
n/v/diarrhea , dysuria and subjective fevers and chills. She also
reports some back pain. No melena , BRBPR. No gross
hematuria.
PE: T= 99.0 HR= 72 BP=130-170/82-96 in R arm , 102-130/82-100 in L arm.
R=20 02sat= 95 RA. NAD , PERRL , slightly dry MM. JVP 7cm. RRR Nl s1 and
s2. 2/6 SEM audible throughout. No r/g. Lungs CTAB. Abd Soft , ND.
Bsx4. Diffusely tender. NO CVAT. Poor DPP pulses. No
edema.
A/P: 66 y'o owman with HTN , DM , known CAD p/with n/v/f/c
abd pain found to have a UTI and ARF. Also notable on admission were
ST depressions in V3-V5.
1 ) ID-UTI - Rx with ciprofloxacin. Urine cxs notable for greater than
100.00 E. Coli. Blood cx without growth. Improvement in abd pain and CVAT
after one day of treatment with intravenous ciprofloxacin.
2 ) Renal - ARF likely prerenal in the setting of
UTI/infection and pre-renal state. NS followed by maintenance with
complete return to baseline renal function.
3 ) CV - Pump: euvolemic. Holding lasix in the setting of UTI. Hx of
asymmetric BPs secondary to stenosis.
Rhythm: First degree AV block , intermittent Wenkebach but infrequently
dropped beats so no contraindication to nodal blockade.
Telemetry. Ischemia: ST depressions in V3-V% resolved during hospital
course. MI r/o with 3 sets of negative enzymes. One episode of jaw pain ,
relieved with sublingual nitroglycerin. No EKG changes. Will need outpatient stress
test - ETT MIBI or adenosine MIBI.
4 ) Endo- ISS
5 ) FEN - DVT prophylaxis , cardiac diet
FULL CODE
FULL CODE
2 ) Renal
ADDITIONAL COMMENTS: In addition to your home medications please take Ciprofloxacin 250mg
every 12 hours for 10 days and please take ECASA 81mg once a day. Please
follow-up with your primary care physician at your scheduled appointment.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please insure UTI cleared with Ciprofloxacin.
Please Schedule patient for adenosine or ETT MIBI in light of angina and
recent ST depressions.
No dictated summary
ENTERED BY: PARDON , HALEY , M.D. ( NC57 ) 2/25/05 @ 03:21 PM
****** END OF DISCHARGE ORDERS ******

Document id: 25

392986061 | PUO | 09031082 | | 4655958 | 10/22/2006 12:00:00 a.m. | ALTERED MENTAL STATUS | Unsigned | DIS | Admission Date: 2/17/2006 Report Status: Unsigned

Discharge Date: 2/28/2006
ATTENDING: SPILLETT , SILVA M.D.
ADDENDUM
HOSPITAL COURSE:
Neuro: Starting on 6/13/06 the patient had an episode of
agitation on hemodialysis where he received Ativan and continued
to be agitated and required multiple code greys to sedate him. A
team meeting was held on 8/13/06 and per psychiatry
recommendations the patient was started on 250 mg twice a day of
Depakote , Haldol was reduced to just Monday-Wednesday-Friday 1 mg
before hemodialysis and 1 mg as needed agitation. The patient did
very well on this regimen and his Depakote level was stable at
39.7 on discharge. The plan is to continue Depakote twice a day 250
mg with Haldol as needed for behavior. In terms of his mental
status on discharge , the patient was A&O x3 and appropriate.
In terms of cardiac , there were no additional events to report.
In terms of pulmonary , the patient was diagnosed with pneumonia
on 10/26/06 and started on ceftriaxone intravenous and Flagyl. This was
changed to cefpodoxime and Flagyl for discharge. In terms of his
pneumonia that was evident right lower lobe pneumonia on chest
x-ray and the patient was also spiking fevers and had audible
rales on exam.
In terms of GI , the patient continued tolerate regular diet and
nutrition continued to follow ensuring adequate orally intake and
adjusting diet per endocrine needs.
In terms of endocrine , the addendum to 6/13/06 , the patient
ultimately discontinued on a regimen of 7 units of Lantus every day before noon
and every afternoon with 5 units aspart before every meal breakfast and lunch and 4
units of aspart before every meal dinner. His sliding scale was very light
and he is only to be covered with one to two units of aspart
during the night as insulin stacks in this patient very easily.
It was recommended if the patient is noted to be in the low 100s
consistently through the course of the day that his next dose of
aspart be either halved or held as the patient easily becomes
hypoglycemic and is unable to recognize the symptoms of
hypoglycemia himself. At the time of discharge , the patient's
fingersticks were well controlled in the 100-200 range.
In terms of ID , the patient began to spike fevers on 9/22/06
with a T. max of 100.6 and blood cultures failed to show anything
as did sputum cultures. On 5/18/06 , the patient spiked to 101.2
and had evidence of pneumonia on his chest x-ray. He was started
on antibiotics of ceftriaxone and Flagyl , which was switched to
cefpodoxime and Flagyl for discharge. The cefpodoxime should be
dosed after dialysis on Monday-Wednesday-Friday.
In terms of disposition , the patient has been discharged to rehab
where he will continue hemodialysis on Monday-Wednesday-Friday
and continues to have the same medication Rx as he did well in
house. Specific care should be given to his insulin regimen as
well as his behavior control and nutrition as noted in the
discharge instructions. Again please c.c. Dr. Ma Yeagley , Dr.
Wei Pilling , Dr. Gabhart on this discharge summary.
ADDENDUM TO MEDICATIONS ON DISCHARGE:
PhosLo 2001 mg orally three times a day , Depakote 250 mg orally twice a day , folate 1
mg orally daily , Haldol 1 mg intravenous on Monday-Wednesday-Friday given
prior to hemodialysis , labetalol 350 mg orally twice a day , lisinopril
80 mg orally daily , Flagyl 500 mg orally three times a day for 14 days , thiamine
100 mg orally daily , Norvasc 10 mg orally daily , gabapentin 300 mg
orally every bedtime , cefpodoxime 200 mg orally three times a week on
Monday-Wednesday-Friday for eight doses given after hemodialysis ,
Nephrocaps one tablet orally daily , sevelamer 2004 mg orally three times a day ,
Advair diskus 250/50 one puff twice a day , Nexium 20 mg orally daily ,
Lantus 7 units subcutaneous twice a day once in the morning and once
evening , aspart 4 units subcutaneous before dinner and 5 units
subcutaneous before breakfast and 5 units subcutaneous before
lunch , aspart sliding scale starting at blood sugar less than 125
give 0 units , blood sugar 125-300 give 0 units , blood sugar
301-350 give 1 unit , blood sugar 351-400 give 2 units , blood
sugar 400-450 give 2 units , albuterol butt paste topical daily ,
and then as needed Tylenol 650 mg as needed pain , headache , or
temperature , albuterol inhaler as needed wheezing , Haldol 1 mg intravenous q.
6h. as needed agitation. If more than three doses given in a day
please check QTC on the EKG. Loperamide 2 mg orally every 8 hours as needed
diarrhea.
eScription document: 6-0295725 EMSSten Tel
CC: Ma Yeagley M.D.
Beach Sa Son
CC: Wei Pilling M.D.
Pagham University Of
Ren Ley An
CC: Dorthy Gabhart M.D.
Ly Mo Dia
Dictated By: EISENHAVER , KAREN
Attending: SPILLETT , SILVA
Dictation ID 3816680
D: 5/23/06
T: 5/23/06

Document id: 26

376950295 | PUO | 84780901 | | 8136148 | 6/21/2006 12:00:00 a.m. | MYOCARDIAL INFARCTION | Signed | DIS | Admission Date: 4/12/2006 Report Status: Signed

Discharge Date: 1/10/2006
ATTENDING: HARTSELL , DANILLE L. MD
ADDENDUM
The patient is a 76-year-old male with a history of diabetes ,
hypertension , CAD status post MI in 2000 who presented with an ST
elevation MI to the Emergency Room on 8/23/06 .  He was brought
to Cath where he was found to have in-stent thrombosis in his LAD. The clot was
aspirated and bare-metal stent was placed in his LAD
and another stent was placed in his diag-2. He suffered multiple V-Tach
cardiac arrests requiring CPR and cardioversion. In the
Cath Lab , he was given bicarb , placed on the epi drip , given
Lasix and was intubated. He was thought to aspirate at the time
of intubation secondary to vomiting. A bedside echo revealed
global hypokinesis with an EF of 35%. He , at that time , was
placed on a balloon pump , dopamine 16 , amio 1 , propofol 1 , and
Integrilin and brought to the CCU. On the floor , his blood
pressures were difficult to control and his PA catheter readings
indicated a wedge pressure of 47. His MAPs were marginal and max dopamine , max
Levophed , epinephrine and dobutamine were required to maintain a minimal blood
pressure.
His family was aware of his prognosis and was there at the time
of his arrest at 3:30 in the morning. CPR was initiated , and
ACLS was performed until the family decided to terminate the ACLS. At that
time , there were no spontaneous breath sounds , no heart sounds , and nonreactive
pupils. The cause of death was thought to be cardiogenic shock
secondary to ST elevation MI. His time of death was 3:47 a.m. on 8/23/06 .
eScription document: 8-2199247 EMSSten Tel
Dictated By: ALEXIS , LEAH
Attending: HARTSELL , DANILLE L.
Dictation ID 8723980
Addendum Created by HARTSELL , DANILLE LACY , M.D.
A: 6/20/06
Dictation ID: 0083618ZAN

Document id: 27

461171537 | PUO | 89762298 | | 2890032 | 1/1/2004 12:00:00 a.m. | hereditary angioedema | | DIS | Admission Date: 10/22/2004 Report Status:

Discharge Date: 6/21/2004
****** DISCHARGE ORDERS ******
BLANN , GLENNA A. 009-06-32-4
Sundvik Dr. , Leashampinewoodwood Smouth Aank
Service: CAR
DISCHARGE PATIENT ON: 6/21/04 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: VERRY , COLETTA F. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
ATENOLOL 75 MG orally every day
DANAZOL 200 MG orally three times a day
DIGOXIN 0.125 MG orally every other day
Override Notice: Override added on 3/1/04 by
TOLLEFSON , AHMED , M.D.
on order for SYNTHROID orally ( ref # 75444907 )
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM Reason for override: mda
DIGOXIN 0.187 MG orally every other day
Instructions: alternate digoxin doses
Override Notice: Override added on 3/1/04 by
TOLLEFSON , AHMED , M.D.
on order for SYNTHROID orally ( ref # 75444907 )
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM Reason for override: mda
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
PEPCID ( FAMOTIDINE ) 20 MG orally every day
LASIX ( FUROSEMIDE ) 20 MG orally every day
Alert overridden: Override added on 3/1/04 by
TOLLEFSON , AHMED , M.D.
on order for LASIX orally ( ref # 83364415 )
patient has a POSSIBLE allergy to Sulfa; reaction is RASH.
Reason for override: mda
SYNTHROID ( LEVOTHYROXINE SODIUM ) 50 MCG orally every day
Alert overridden: Override added on 3/1/04 by
TOLLEFSON , AHMED , M.D.
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM
POTENTIALLY SERIOUS INTERACTION: DIGOXIN & LEVOTHYROXINE
SODIUM Reason for override: mda
RHINOCORT ( BUDESONIDE NASAL INHALER ) 1 SPRAY nasal twice a day
ALLEGRA ( FEXOFENADINE HCL ) 60 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ZANTAC ( RANITIDINE HCL ) 150 MG orally every day
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Rolson 611-870-7831 Wednesday , July , 9:15am- Connecticut scheduled ,
ALLERGY: intravenous Contrast , Sulfa , Penicillins , QUINIDINE SULFATE ,
LEVOFLOXACIN , LISINOPRIL , NITROFURANTOIN , STANAZOL ,
PROCAINE HCL , Dairy Products , WHEAT/GLUTEN ,
NITROFURANTOIN MACROCRYSTAL
ADMIT DIAGNOSIS:
hereditary angioedema
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
hereditary angioedema
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
HEREDITARY ANGIOEDEMA AFIB - lodose Coum/ASA HYPOTHY
history of SUBDURAL ON COUM history of APPY , TAH tracheostomies x
3 multiple intubations DVT , ivc filter in place GERD polycythemia
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
82 year-old femalew tih long hx of hereditary angioedema- history of multiple
remote prior tracheostomies due to airway edema- now admitted with lip
swelling. In recent years , her primary symptoms have been GI in
nature- with bowel swelling/ N/V/abdominal pain. Has been maintained
on stanazol previously , but on danazol for the last several years.
Patient had a recent admission for LGIB - outpatient elective
colonoscopy ultimately showed a stricture which was dilated. She had
persistent GI symptoms which were thought likely due to an angioedema
attack and her danazol was increased to 200 twice a day In the last week ,
patient was in the midst of tapering this medication down with her
Allergist Dr. Paulauskis , but has now developed upper lip swelling on day
of admission- which appeared to be worsening in the ED.
PMHx: notable for colonic strictures , DVT history of IVC filter , ?DM , HTN ,
afib , CAD history of MI , history of sigmoid colostomy.
Long list of allergies including intravenous contrast , PCN , levaquin.
Meds include danazole 100 every day.
On exam , - afebrile , 99%ra , blood pressure 105/80 , heart rate 80s. sitting up comfortably ,
able to speak with slightly muddled pronouncitation. Left upper lip
swelling to twice size of normal right side. No uvula swelling noted.
No stridor or increased secreations. Lungs clear. Irregular heart rate
with 3/6 HSM at LLSB. Faint crackles at bases. No rashes noted.
Labs remarkable only for Cr 1.2 ( basline ). Normal CBC , Normal coags.
C1Q/c4/c2/c1 esterase inhibitor results all pending.
Impression/Hospital course:
82 year-old F with heriditary angioedema , presenting with lip swelling.
Patient was admitted to CCU for observation in case of airway
instability. She was treated with higher dose danazol ( 200 three times a day ) as well
as FFP ( for which she was premedicated with benadryl ). FFP replaces
C1 esterase inhibitor. She required single dose of intravenous lasix to maintain
I/O status during FFP infusion. She had rapid improvement over 24-48
hours with no signs of airway compromise. She will be followed closely
by her allergist and will leave on a higher dose of danazol. There is
some consideration of re-instituting stanazol in the future.
------
f/u with allergist Dr. Rolson in 5 days
f/u complement panel studies
ADDITIONAL COMMENTS: return to the hospital if you notice any lip swelling or difficulty
breathing
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: MALADY , CASSONDRA F. , M.D. , M.S. ( JZ49 ) 6/21/04 @ 02:01 PM
****** END OF DISCHARGE ORDERS ******

Document id: 28

242838255 | PUO | 76068155 | | 9428895 | 4/29/2005 12:00:00 a.m. | LEFT LEG WOUND INFECTION | Signed | DIS | Admission Date: 9/4/2005 Report Status: Signed

Discharge Date: 10/21/2005
ATTENDING: FIONA AUTHUR M.D.
ADMITTING DIAGNOSIS:
Bilateral lower extremity wound infection.
DISCHARGE DIAGNOSIS:
Bilateral lower extremity wound infection.
ALLERGIES:
Lisinopril and atenolol.
PAST MEDICAL HISTORY:
Includes chronic venous stasis ulcers in lower extremities ,
diabetes mellitus , hypertension , asthma , sarcoid , restricted
pulmonary disease , and obesity.
HOSPITAL COURSE:
This is a 60-year-old female with a history of chronic venous
stasis ulcers of bilateral lower extremities admitted to the Plastic
Surgery service with infection on 11/9/05 .  The patient was
treated with intravenous vancomycin and levofloxacin and the patient has
been afebrile during the stay. She has been getting dressing
changes with acetic acid solution three times a day on her lower
extremity ulcers bilaterally. Over the course of the days the
ulcer looks pretty clean and very nice and she has been doing
very good. Her pain is well controlled and she has been treated
with the bed rest , intravenous antibiotics , and the dressing changes. She
has been told to keep her legs elevated most of the time , so that
the swelling will decrease , and the patient has been afebrile
with the stabe vital signs. She has been taking orally and been
voiding. She has been ambulating independently from bed to bath
and chair and her pain has been well controlled. The lower
extremity wounds are getting well and there is no evidence of any
purulent discharge or evidence of infection. While the patient
was here , her vancomycin and levofloxacin have been discontinued
and the patient is switched to Bactrim double strength as the
wound culture revealed Achromobacter and xylosoxidans , which was
sensitive. The patient will be discharged to home today with the
visiting nurse and services. The patient will return back in
several weeks for the further reconstruction and wound culture
most probably skin grafting.
CONDITION ON DISCHARGE:
Stable.
ACTIVITY:
Legs elevated when not walking.
DIET:
Regular house diet and diabetic diet.
FOLLOW UP APPOINTMENTS:
Dr. Authur , please call to schedule ( 035 )-052-8582 in 7-10 days.
DISCHARGE INSTRUCTIONS:
Dressing changes with 0.25% of acetic acid/1 liter normal saline used
for soaks and dressings.
DISCHARGE MEDICATIONS:
Aspirin 81 mg orally every day , calcium carbonate 500 mg orally twice a day ,
Colace 100 mg orally twice a day , Lasix 40 mg orally every day , NPH insulin
Humulin 40 units every day before noon and 28 units every afternoon subcutaneous ,
labetolol 200 mg orally twice a day , Percocet 5-10 mg orally every 4 hours as needed
for pain and multivitamin therapeutic one tablet orally every day , Zocor
20 mg orally every bedtime , Norvasc 5 mg orally every day , metformin 500 mg orally
three times a day , Cozaar 100 mg orally every day , acetic acid 0.25% topical three times a day
instruction , mixed with 1 liter normal saline for three times a day wet to
dry soak and dressing changes , and Bactrim DS one tablet orally
every 12 hours for two weeks.
eScription document: 5-9424390 EMSSten Tel
Dictated By: KALINGER , NAKESHA
Attending: AUTHUR , FIONA
Dictation ID 5269372
D: 11/12/05
T: 11/12/05

Document id: 29

759646448 | PUO | 39691196 | | 739929 | 7/15/1999 12:00:00 a.m. | FAILED LT. TOTAL HIP REPLACEMENT | Signed | DIS | Admission Date: 7/15/1999 Report Status: Signed

Discharge Date: 9/13/1999
ADMITTING DIAGNOSIS: FAILED LEFT BIPOLAR HEMIARTHROPLASTY
DISCHARGE DIAGNOSIS: CONVERSION TO LEFT TOTAL HIP REPLACEMENT
DATE OF SURGERY: 10/15/99
HISTORY OF PRESENT ILLNESS: The patient is a 50 year-old male with
a history of left hip
hemiarthroplasty for avascular necrosis in 10/27 as well as right
hip hemiarthroplasty in 1982. He now has groin pain on the left
side that is worsening. This has been increasing over the past
year. It limits his activity. He is admitted for elective
conversion to a total hip replacement.
PAST MEDICAL HISTORY: Hypertension , asthma , cardiomyopathy , gout ,
tympanoplasty , hernia repair.
ALLERGIES: None.
CURRENT MEDICATIONS: Diltiazem 120 mg twice a day , Theophylline 200
three times a day , Warfarin 6 mg every day , Lasix 80 mg every
day , Indomethacin 25 mg twice a day , cyclobenzoprine 10 three times a day ,
Lisinopril 20 mg every day , K-Dur 20 mEq every day , Isosorbide dinitate 20
mg three times a day , Allopurinol 300 mg every day , Albuterol inhaler two four times a day ,
Salmetrol inhaler two puffs twice a day
HOSPITAL COURSE: The patient was taken to the operating room on
10/15/99 where he underwent an uncomplicated
conversion of his bipolar hemiarthroplasty to a total hip
arthroplasty. Please refer to the dictated operative note for
details of this procedure. The patient tolerated the procedure
well and remained stable postoperatively without complications.
His diet was advanced without difficulty. The patient tolerated
orally pain medication without difficulty. The patient received three
units of autologous blood perioperatively for a low hematocrit. He
was given stress dose steroids. The patient was started on
Coumadin for deep venous thrombosis prophylaxis. The patient
received physical therapy consultation and was made partial weight
bearing with range of motion exercises and continuous passive
motion machine with posterior dislocation precautions. The
patient was discharged to home in stable condition with services on
6/26/99 .  He will follow up with Dr. Nwankwo .
MEDICATIONS ON DISCHARGE: Include those on admission plus the
addition of Percocet 1-2 tablets orally every
4h as needed pain and Coumadin adjusted dose to maintain an INR Of
1.5-2.0 for deep venous thrombosis prophylaxis.
Dictated By: SILVIA GREENFELDER , M.D. GB16
Attending: REBEKAH NWANKWO , M.D. HI3  MV054/9024
Batch: 7913 Index No. P4GR5O9ACS D: 6/21/99
T: 6/21/99

Document id: 30

125960861 | PUO | 68313462 | | 461521 | 7/9/2000 12:00:00 a.m. | leg edema , anemia , proteinuria , ?NSAID gastritis , colonic polyps | | DIS | Admission Date: 7/9/2000 Report Status:

Discharge Date: 5/2/2000
****** DISCHARGE ORDERS ******
MANNIS , FATIMA 432-90-08-5
Da
Service: MED
DISCHARGE PATIENT ON: 1/25 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BYE , NATHANIAL K. , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
VENTOLIN ( ALBUTEROL INHALER ) 2 PUFF inhaled four times a day
as needed wheezing , sob
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LASIX ( FUROSEMIDE ) 100 MG orally twice a day
NPH HUMULIN INSULIN ( INSULIN NPH HUMAN ) 20 U subcutaneously every afternoon
Starting Today ( 7/18 ) HOLD IF: 1 )NPO 2 ) till scope is done
REGULAR INSULIN ( HUMAN ) ( INSULIN REGULAR HUMAN )
Sliding Scale subcutaneously before every meal & HS Call HO If BS > 400
For BS < 200 give 0 Units reg subcutaneously
For BS from 201 to 250 give 4 Units reg subcutaneously
For BS from 251 to 300 give 6 Units reg subcutaneously
For BS from 301 to 350 give 8 Units reg subcutaneously
For BS from 351 to 400 give 10 Units reg subcutaneously
ZESTRIL ( LISINOPRIL ) 40 MG orally every day
Override Notice: Override added on 9/8 by FRINK , TENA S S. , M.D. on order for GOLYTELY orally ( ref # 05549917 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: noted
Previous override information:
Override added on 11/22 by KRIKORIAN , JOLYNN LORE , M.D.
on order for KCL IMMEDIATE REL. orally ( ref # 99266015 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: aware
Previous override information:
Override added on 7/06 by BUSSLER , FRAN SHIRLEEN , M.D.
on order for KCL intravenous ( ref # 57747927 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
Previous override information:
Override added on 7/06 by BUSSLER , FRAN SHIRLEEN , M.D.
on order for KCL IMMEDIATE REL. orally ( ref # 99588520 )
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
REGLAN ( METOCLOPRAMIDE HCL ) 10 MG orally twice a day
Starting Today ( 7/18 )
Instructions: take with lasix to increase absorption
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
CARDURA ( DOXAZOSIN ) 4 MG orally twice a day
AVANDIA ( ROSIGLITAZONE ) 8 MG orally every day
KCL SLOW RELEASE 20 MEQ X 2 orally every day
As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
Alert overridden: Override added on 1/25 by :
POTENTIALLY SERIOUS INTERACTION: LISINOPRIL & POTASSIUM
CHLORIDE Reason for override: will monitor
DIET: House / ADA 1800 cals/dy
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Bye 3:45pm 6/15 scheduled ,
ALLERGY: Erythromycins , Penicillins , Cortisone acetate
ADMIT DIAGNOSIS:
leg edema , anemia , proteinuria
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
leg edema , anemia , proteinuria , ?NSAID gastritis , colonic polyps
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
IDDM HTN nephrotic sdm Fe def anemia CHF ( EF 40-45% on
OPERATIONS AND PROCEDURES:
Upper GI: NSAID gastritis , hiatal hernia
Colonoscopy: Polyps that appeared benign , no evidence of bleeding
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Blood transfusions ( three units total )
Diuresis with intravenous lasix
BRIEF RESUME OF HOSPITAL COURSE:
*** 11/22 ***
60 year-old woman c dm , htn , hyperlipidemia , nephrotic syndrome p/with
worsening 3+ le edema up to thighs and lower abdomen. No cp , sob ,
palpitations , dysuria , change in urination. Protein loss in
10 of September around 6g/day. Also Hct decrease in past
months , guaiac + stool in ED. Admitted for diuresis
and possible GI workup.
____________________________________________________________
*** 6/10 ***
colonoscopy today: mult ( about 10 ) polyps in colon , largest one 1cm ,
no active bleeding. No polyp bx taken , given so numerous and patient
on ASA and lovenox. Nodular
gastritis with few erosions , no ulcers. Gastric bx pending.
patient to get repeat colonoscopy in February with bx of
polyps , after d/c asa ,
lovenox.
Sent home on 100 mg twice a day orally Lasix with 10mg twice a day orally Reglan to increase
absorption , on rest of cardiac meds ( Zestril , Cardura ) , on Avandia and
Humalin 20 Units. Avoid NSAIDS and ASA. primary care physician will adjust diuretic
regimen as patient responds.
ADDITIONAL COMMENTS: Please visit Dr. Bye or come back to PUO if leg edema worsens with
diuretic use at home or if notice blood in stools.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Follow up with Dr. Bye tomorrow 3:45pm at Tempson Neistone Ino Hospital .
Follow up with GI at PUO in 2 months for colonic polyps.
Avoid NSAIDs , Aspirin
Follow-up H.pylori study.
Adjust diuretic regimen as needed. patient aware of fluid restriction need
of about 1.5L/day and plan.
No dictated summary
ENTERED BY: BUSSLER , FRAN SHIRLEEN , M.D. ( HE58 ) 1/25 @ 02:34 PM
****** END OF DISCHARGE ORDERS ******

Document id: 31

778562534 | PUO | 93827167 | | 1545525 | 3/8/2003 12:00:00 a.m. | anemia | | DIS | Admission Date: 11/11/2003 Report Status:

Discharge Date: 6/20/2003
****** DISCHARGE ORDERS ******
SORICELLI , DOYLE 772-44-89-4
Tempe Mi Veale
Service: MED
DISCHARGE PATIENT ON: 6/24/03 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NAJI , COLIN ELINORE , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
HCTZ ( HYDROCHLOROTHIAZIDE ) 25 MG orally every day
LEVOXYL ( LEVOTHYROXINE SODIUM ) 150 MCG orally every day
VITAMIN E ( TOCOPHEROL-DL-ALPHA ) 400 UNITS orally every day
MVI THERAPEUTIC ( THERAPEUTIC MULTIVITAMINS ) 1 TAB orally every day
Override Notice: Override added on 3/2/03 by LALATA , JOHNETTA B JOLYN , M.D. on order for SIMVASTATIN orally ( ref # 40253317 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: aware.
ECASA ( ASPIRIN ENTERIC COATED ) 81 MG orally every day
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
Alert overridden: Override added on 6/24/03 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: aware.
ATENOLOL 25 MG orally every day
DIET: House / Low chol/low sat. fat
DIET: 4 gram Sodium
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Please follow up with Dr. Donehoo in Hematology Clinic next week. Call 922-441-5130 for appt. ,
Please follow-up with your primary care physician. Call for appt. ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
GI bleed , anemia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
anemia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Thrombocytopenia ( ?ITP ) Osteoarthritis
history of polymyalgia rheumatica history of spinal stenosis
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Colonoscopy/EGD on 1/29 -- EGD c no ulcerations , biopsy taken.
Colonoscopy c 1 polyp , removed , also c multiple diverticuli , no
evidence of blood/bleeding.
BRIEF RESUME OF HOSPITAL COURSE:
72yoF c 6cm descending thoracic aneurysm , history of diverticulosis , presented
to primary care physician office c 1 week history of increasing fatigue c exertion , possible DOE.
Also c intermittent upper back pain , only on exertion , but not clearly
reproducible. Hct from primary care physician office 21 , sent to PUO ED for further
workup. H/o some blood in toilet am of admission , o/with denied GI sx.
Trace guaiac positive in ED. Hospital course as follows:
1. HEME -- patient was tx'd 2 U PRBC in ED c Hct response to 25.
Reticulocyte count was 1.1 and iron studies , B12 , folate prior to
transfusion were within nl limits. A chest CT was obtained re: her
thoracic aneurysm , which showed a chronic dissection , aneurysmal
diameter of 6 cm , but no change from previous. Hemolysis labs were
negative. patient was transfused an add'l 2 U PRBC on floor and responded
appropriately. Given her low retic count , there was suspicion she
could have a primary hematologic dz , and she is to follow up with Dr.
Donehoo in clinic at SSR next week.
2. CARD -- patient had some DOE , which was thought to be related to
her anemia. She had negative cardiac enzymes in ED. EKG s changes ,
isolated TwI in III. She was maintained on her usual outpt regimen.
3. GI -- There was a consideration of a possible GI source , given
patient's history. GI was consulted and she received EGD/colonoscopy ,
which revealed extensive diverticulosis , but no evidence of bleeding.
patient is being discharged to home to follow-up with Hematology and with
her primary care physician.
ADDITIONAL COMMENTS: 1. If you have increasing episodes of fatigue with exercise , please
call your primary care physician and arrange for an appt , or come to
the Emergency Department.
2. Please go to your primary care physician's office to have your
blood level ( Hct ) checked on Monday 2/30/03 .
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Check Hct in your primary care physician's office on Monday.
2. Call the Hematology Clinic at 922-441-5130 to schedule a follow-up
appt with Dr. Donehoo next week.
No dictated summary
ENTERED BY: LALATA , JOHNETTA BEN , M.D. ( UB074 ) 6/24/03 @ 12:30 PM
****** END OF DISCHARGE ORDERS ******

Document id: 32

712371137 | PUO | 91183152 | | 2181806 | 1/12/2005 12:00:00 a.m. | Ventral Hernia | | DIS | Admission Date: 6/12/2005 Report Status:

Discharge Date: 4/17/2005
****** FINAL DISCHARGE ORDERS ******
BARTLET , DIANNE L 274-56-92-7
T
Service: GGI
DISCHARGE PATIENT ON: 5/21/05 AT 10:00 a.m.
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: COHENS , ANGELINE VICKI , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
SYNTHROID ( LEVOTHYROXINE SODIUM ) 150 MCG orally every day
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
LEVOFLOXACIN 500 MG orally every 24 hours
DIET: No Restrictions
ACTIVITY: Walking as tolerated
Lift restrictions: Do not lift greater then 15 pounds
FOLLOW UP APPOINTMENT( S ):
Dr. Cohens 1-2weeks ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
Ventral Hernia
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Ventral Hernia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Ventral hernia , hypothyroid , history of obesity
OPERATIONS AND PROCEDURES:
6/22/05 COHENS , ANGELINE VICKI , M.D.
VENTRAL HERNIA REPAIR WITH MESH
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
NONE
BRIEF RESUME OF HOSPITAL COURSE:
Patient is 58 year-old F who is history of ventral hernia repair. She had an
uncomplicated surgery. She was transferred to the floor and had some
nausea with the morphine PCA overnight. She vomited in the a.m. from the
morphine and it was d/c'd and after orally pain meds she improved greatly.
She had her foley d/c'd and she was pain free all day ( POD1 ). She is on
her synthroid ( 150mcg ) and is ready for d/c home with VNA on levofloxacin
until the drains are removed.
ADDITIONAL COMMENTS: VNA: Please empty the drains and change the dressing every day. Please record
the volume of output.
Keep dressing clean and dry. You may remove the dressing 2 days after
surgery to shower. Leave the steri strips on as they will fall off on
their own. The dressing around the drain will be replaced by VNA.
Stay on the antibiotics until you see Dr. Cohens .
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Follow up with Dr. Cohens .
Stay on Antibiotics until told not to take them anymore.
No dictated summary
ENTERED BY: SPRATTE , DESIRE M. , M.D. ( EN577 ) 5/21/05 @ 08:54 a.m.
****** END OF DISCHARGE ORDERS ******

Document id: 33

759889792 | PUO | 12278269 | | 1944823 | 3/28/2007 12:00:00 a.m. | same | | DIS | Admission Date: 1/10/2007 Report Status:

Discharge Date: 3/20/2007
****** FINAL DISCHARGE ORDERS ******
HAMMETT , FREDERICA 806-57-80-1
Derd I Ecoyork
Service: VAS
DISCHARGE PATIENT ON: 9/15/07 AT 01:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: YOUNGBERG , JERICA TANYA , M.D.
CODE STATUS:
Full code
DISPOSITION: Rehabilitation
MEDICATIONS ON ADMISSION:
1. ACETYLSALICYLIC ACID 81 MG orally every day
2. ALBUTEROL INHALER 2 PUFF inhaled four times a day
3. CALCITRIOL 0.25 MCG orally every day
4. CLOPIDOGREL 75 MG orally every day
5. DOCUSATE SODIUM 100 MG orally twice a day
6. FOLIC ACID 1 MG orally every day
7. FUROSEMIDE 10 MG orally every day
8. GABAPENTIN 100 MG orally three times a day
9. IPRATROPIUM INHALER 2 PUFF inhaled four times a day
10. LISINOPRIL 2.5 MG orally every day
11. METOPROLOL SUCCINATE EXTENDED RELEASE 50 MG orally every day
12. NIFEREX 150 150 MG orally twice a day
13. OMEPRAZOLE 20 MG orally every day
14. OXYCODONE 10 MG orally every 4 hours
MEDICATIONS ON DISCHARGE:
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ACETYLSALICYLIC ACID 81 MG orally DAILY
DUONEB ( ALBUTEROL AND IPRATROPIUM NEBULIZER )
3/0.5 MG NEB every 6 hours
DUONEB ( ALBUTEROL AND IPRATROPIUM NEBULIZER )
3/0.5 MG NEB every 6 hours as needed Shortness of Breath , Wheezing
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed Wheezing
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FOLATE ( FOLIC ACID ) 1 MG orally DAILY
LASIX ( FUROSEMIDE ) 10 MG orally DAILY
NEURONTIN ( GABAPENTIN ) 100 MG orally three times a day
HEPARIN 5 , 000 UNITS subcutaneously every 8 hours
INSULIN REGULAR HUMAN
Sliding Scale ( subcutaneously ) subcutaneously before meals+HS Low Scale
Call HO if BS less than 60
If BS is less than 125 , then DO NOT Administer
supplemental ( sliding scale ) insulin
If BS is 125-150 , then give 0 units subcutaneously
If BS is 151-200 , then give 1 units subcutaneously
If BS is 201-250 , then give 2 units subcutaneously
If BS is 251-300 , then give 3 units subcutaneously
If BS is 301-350 , then give 4 units subcutaneously
If BS is 351-400 , then give 5 units subcutaneously
Call HO if BS is greater than 350
If receiving standing regular insulin , please give at same
time and in addition to standing regular insulin
LISINOPRIL 2.5 MG orally DAILY
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
MILK OF MAGNESIA ( MAGNESIUM HYDROXIDE )
30 MILLILITERS orally DAILY as needed Constipation
LOPRESSOR ( METOPROLOL TARTRATE ) 25 MG orally three times a day
HOLD IF: sbp < 95 or heart rate < 65
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
OMEPRAZOLE 20 MG orally DAILY
OXYCODONE 5-10 MG orally every 3 hours as needed Pain
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
DIET: House / ADA 1800 cals/dy
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Youngberg , 590-882-9425 1 week ,
Primary care physician please call to make appt ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Non-healing left foot wound
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
same
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hypertension ( hypertension ) pernicious anemia ( pernicious anemia )
copd ( chronic obstructive pulmonary disease ) pneumonia
( pneumonia ) CRI ( chronic renal dysfunction )
OPERATIONS AND PROCEDURES:
7/28/07 YOUNGBERG , JERICA TANYA , M.D.
DEBRIDEMENT LT FOOT
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None.
BRIEF RESUME OF HOSPITAL COURSE:
Patient was admitted to Lakesmi Sonno Memorial Hospital surgery service on
3/28/2007 for preoperative evaluation/clearance. On 4/14 she was
taken to the operating room where she underwent debridement of her
non-healing left TMA site No concerning intraoperative events occurred;
please see dictated operative note for details. In the PACU she was
noted to be oozing from several points within the wound bed. Two silk
stitches were placed with improved hemostasis. On POD 1 , the oozing
continued and her hct had dropped to 21. She remained hemodynamically
stable but given her cardiovascular history she was transfused a total of
4 units of blood over the next 2 hospital days. Surgicell was also placed
into the wound bed with adequate hemostasis. The remainder of her
hospital course was unremarkable. Patient had adequate pain control and
was tolerating sips on POD0 and was advanced to regular diet by POD1.
She remained neurologically intact postoperatively. Her blood pressure
remained at baseline ( SBP 110-140s ). She was kept on perioperative
Vanc/Levo/Flagyl throughout her hospitalization. On POD 4 , she was
discharged to rehab in stable condition , afebrile , voiding independently ,
with adequate pain control. Her wound had areas of granulation; will
plan to continue wet-to-dry dressings with normal saline for gentle
debridement. Will reevaluate for VAC dressing and possible eventual skin
graft closure on follow up. She was given explicit instructions to
follow-up in clinic with Dr. Youngberg in 1 week.
ADDITIONAL COMMENTS: ADDITIONAL COMMENTS: If you experience fever , increasing pain ,
redness/drainage from your foot , chest pain , shortness of
breath or other concerning symptoms , please seek medical attention
immediately
-Resume medications as prescribed
-Rehab should continue with wet to dry dressings with normal saline to L
TMA wound twice a day.
-ACTIVITY: touch down weight bearing left leg
-ANTICOAGULATION:please continue aspirin and plavix
-Please schedule and attend follow-up appointment with Dr. Youngberg in
1-2 weeks
DISCHARGE CONDITION: Stable
TO DO/PLAN:
please see above instructions/plan
No dictated summary
ENTERED BY: CHOJNACKI , ZACHARY R. , M.D. ( GG08 ) 9/15/07 @ 08:08 a.m.
****** END OF DISCHARGE ORDERS ******

Document id: 34

378576931 | PUO | 59506466 | | 6678991 | 4/13/2005 12:00:00 a.m. | HEPATIC ABSCESS | Signed | DIS | Admission Date: 5/19/2005 Report Status: Signed

Discharge Date: 4/23/2005
ATTENDING: FREHSE , MARILYN MD
UMZEE MEDICAL CENTER
HISTORY OF PRESENT ILLNESS:
This is a 66-year-old female with a history of coronary artery
disease , chronic atrial fibrillation on Coumadin , pulmonary
hypertension , insulin dependent diabetes mellitus , hypothyroidism
who presented in 5/25 with an apparent perforated appendicitis
for which she was taken to the operating room. Final pathology
during this procedure was serositis. Her postoperative course
was complicated by severe delirium , atrial fibrillation ,
abdominal abscesses requiring IR drainage in 10/10 and 10/7 .
The patient began having recurrent UTI , decreased appetite and
hematochezia at this time. On 8/17/05 , a CT of the abdomen
showed evidence of a colovesical fistula and the patient was
admitted to the Arvai Sonprince Hospital for further management.
On admission , she was found to be in acute renal failure with a
creatinine of 2.3 apparently secondary to dehydration after
recently having been started on Lasix for hypertension by her
primary care physician.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Pulmonary hypertension.
3. Chronic atrial fibrillation , on Coumadin.
4. Hypercholesterolemia.
5. Asthma.
6. Insulin dependent diabetes mellitus.
7. Hypothyroidism.
PAST SURGICAL HISTORY:
Appendectomy in 5/25 .
MEDICATIONS AT HOME:
1. Atrovent twice a day
2. Metaxalone 2.5 mg daily.
3. Lipitor 10 mg daily.
4. Lasix 60 mg daily.
5. Atenolol 50 mg twice a day
6. Diltiazem 120 mg daily.
7. Potassium chloride 10 mg twice a day
8. Colace 100 mg three times a day
9. Folate.
10. Re1glan as needed
11. Lisinopril 20 mg daily.
12. Wellbutrin 100 mg daily.
13. Protonix 40 mg daily.
14. Coumadin.
ALLERGIES:
No known drug allergies.
HOSPITAL COURSE:
The patient was admitted to the Survtheast Centex Health Care .  Her creatinine
improved with intravenous hydration on 3/25/05 .  She was taken to the
operating room for exploratory laparotomy , cystoscopy with
bilateral urinary stent placement , sigmoid colectomy with primary
anastomosis and diverting ileostomy. During the surgery , she
became hypotensive requiring pressors due to inability to replace
intravenous fluid adequately. She was transferred to the surgical
intensive care unit , intubated on pressors. For the first
several days , she had a inflammatory response-type picture with
significant vasodilation requiring pressors and massive intravenous
resuscitation greater than 30 liters of fluid. Sedation was
slowly weaned as the patient's respiratory status improved. Due
to a question of responsiveness during the first several days , a
head CT was performed which showed no evidence of stroke. She
became slowly more responsive as sedation was weaned with the use
of Precedex and was extubated on 1/22/05 , postoperative day 7
without complications. Her mental status in the intensive care
unit continued to improve. The remainder of the patient's
hospital course will be dictated via systems.
Neurologically , at the time of transfer out of the ICU , the
patient was noted to have subtly improving mental status. Her
family described her at baseline. During her stay on the floor ,
her Zyprexa dose was decreased. She had no further neurologic
issues.
Cardiovascular: In the intensive care unit , the patient required
vasopressin initially and was weaned off during the first three
or four days. Her chronic atrial fibrillation continued. She
was transferred out of the intensive care unit on intravenous Lopressor
which was gradually converted to orally as she tolerated a regular
diet. She was discharged on 100 mg four times a day of Lopressor.
Respiratory: In the intensive care unit , she was noted to have
respiratory failure initially secondary to a SIRS picture and
fluid overload. This significantly improved with diuresis. She
was transferred out on a nasal cannula. On the floor , she had no
respiratory issues. She continued her aggressive chest physical
therapy and was out of bed with physical therapist.
GI: In the Intensive Care Unit , the patient was noted to have a
postoperative ileus. She did not tolerate NG tube feeds. A post
pyloric Dobhoff was eventually placed and tube feeds were
initiated. After transfer out of the intensive care unit , the
patient had difficulty with her Dobhoff catheter and eventually
became clogged and had to be removed. A speech and swallow
evaluation was obtained. A bedside swallow was equivocal and a
fiberoptic swallow was done. She passed this with fine colors
per the speech and swallow team and they recommended that her
diet be advanced as tolerated. She was discharged to
rehabilitation on a regular diet.
GU: In the Intensive Care Unit , she was massively resuscitated
initially and then diuresed for virtually the remainder of her
hospital course. An initial Lasix drip was then changed to intravenous
Lasix boluses. She was discharged on orally Lasix at an equivalent
dose to her standing Lasix during her hospitalization. A
cystogram was obtained prior to her discharge to rehab at the
time of dictation. The result of the cystogram are not
available. If no extravasation is noted , her Foley catheter can
be removed at rehabilitation. If extravasation is noted , she
will need to undergo a repeat cystogram at some point in the
future prior to removal of her Foley catheter.
Heme: The patient was initially on subcutaneously heparin due to concern
for bleeding. She was then started on a heparin drip and was
discovered that she had bilateral lower extremity partial DVTs.
Her heparin drip was titrated to a PTT of 60 to 80 prior to
discharge to rehab. Her heparin was discontinued and she was
started on Lovenox as a bridge to coumadinization. Her Coumadin
began during the few days prior to her discharge when she was
tolerating orally intake.
ID: Due to the colovesical fistula , concern for some liver
opacities on her original abdominal CTs , she was placed on
broad-spectrum antibiotics perioperatively. All antibiotics were
removed on 1/22/05 .  She was noted to have a candidal UTI ,
completed a five-day course of fluconazole. A small fever in the
Intensive Care Unit warranted blood cultures being sent and
repeat blood cultures on 10/4/05 eventually noted a
gram-positive cocci. It was felt that this was likely due to a
contaminant as the patient by that time had been afebrile for
several days. However , she was started on vancomycin for
gram-positive cocci , bacteremia. Her central line was removed
and a new central line was placed and she was discharged to rehab
on day 9 of 14 of intravenous vancomycin via her central line. After the
completion of this course of therapy , her central line may be
removed at rehabilitation.
Wound: Due to some drainage from abdominal wound due to her fat
necrosis , the lower portion of the wound was opened. There was
no evidence of active infection noted and a Vac sponge was placed
initially on 10/4/05 to facilitate the healing process. The Vac
was changed every three days during her stay. This most recent
change was on 10/30/05 .
DISCHARGE CONDITION:
Stable.
DISPOSITION:
Rehabilitation.
DISCHARGE MEDICATIONS:
As indicated on the discharge orders sheet.
eScription document: 4-0875054 EMS
Dictated By: MCRORIE , DENISHA
Attending: FREHSE , MARILYN
Dictation ID 1867475
D: 6/5/05
T: 6/5/05

Document id: 35

246890980 | PUO | 06157825 | | 1415850 | 5/29/2006 12:00:00 a.m. | atypical chest pain | | DIS | Admission Date: 5/7/2006 Report Status:

Discharge Date: 4/14/2006
****** FINAL DISCHARGE ORDERS ******
TOMA , AYAKO 346-42-79-7
Chailus Dr. , Tamp , Ohio 00575
Service: CAR
DISCHARGE PATIENT ON: 10/18/06 AT 04:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: NOLAN , BYRON S.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally DAILY
ALLOPURINOL 150 MG orally DAILY Starting Today ( 10/27 )
LIPITOR ( ATORVASTATIN ) 20 MG orally DAILY
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
ALLEGRA ( FEXOFENADINE HCL ) 180 MG orally DAILY
as needed Other:allergies Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
FLONASE NASAL SPRAY ( FLUTICASONE NASAL SPRAY )
2 SPRAY inhaled DAILY as needed Other:congestion
LASIX ( FUROSEMIDE ) 20 MG orally DAILY
Alert overridden: Override added on 10/18/06 by :
on order for LASIX orally ( ref # 684454380 )
patient has a POSSIBLE allergy to HYDROCHLOROTHIAZIDE;
reaction is Hyponatremia. Reason for override: md aware
ISOSORBIDE MONONITRATE 10 MG orally every 8 hours as needed Chest Pain
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LISINOPRIL 40 MG orally DAILY
Alert overridden: Override added on 10/18/06 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: md aware
METOPROLOL TARTRATE 75 MG orally twice a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
PRILOSEC ( OMEPRAZOLE ) 20 MG orally twice a day
BACTRIM SS ( TRIMETHOPRIM /SULFAMETHOXAZOLE SI... )
1 TAB orally DAILY
Alert overridden: Override added on 10/8/06 by
LARZELERE , GAYLE C. , M.D.
on order for BACTRIM SS orally ( ref # 382576464 )
patient has a PROBABLE allergy to HYDROCHLOROTHIAZIDE;
reaction is Hyponatremia. Reason for override: on at home
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
primary care physician , 7/25 , patient has scheduled ,
ALLERGY: Codeine , PERCOCET , HYDROCHLOROTHIAZIDE , EPTIFIBATIDE
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD , HTN , GERD , GOUT , A FIB , DM , UTI
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
**Chest Pain**
**84 year-old with CAD history of CABG and PCI with chest pain **HPI: CABG in 1998 ,
then PCI with 2 stents. 2/28 found to have restenosed RCA stent , had
balloon angioplasty. Since then chest pain free. Five days
ago , awoke with chest pain , since then mostly nausea , some pain.
Decreased prilosec dose last week. no diaphoresis.
**Patient Status** afebrile , HR 58 , BP 165/80 100% on RA , diffuse
wheezes , RRR , no murmor , soft NTND belly , weak right dp , no left
dp **Studies**
Labs: nml , negative cardiac enzymes
ECG: V paced
**********
A/P: 84 year-old with CAD history of CABG , PCI , and recent balloon angioplasty for
restenosed stent , now with chest pain , in setting of decreased PPI
dose. Most likely atypical chest pain.
1. CV ( i ) low suspicion for
ACS. Patient was ruled out for MI with serial
enzymes/ecgs. Cont ASA , statin ( low dose ) , plavix ,
nitro. ( p ) HTN here:
- continued ACE , gave captopril for lisinopril to titrate - continue B
blocker ( three times a day for twice a day to titrate )r ( r ) sick sinus syndrome with
pacemaker , v paced 2. GI: appears to be with worsening
GERD - continue PPI , increased dose to
twice a day. Patient would benefit from GI
eval as outpatient. H pylori serologies were ordered. 3. Pulm: diffuse
wheezes , no history of pulm dz , patient says
its old. Wheezes resolved by day of discharge. chest cxray neg -
consider
PFTs in future. 4. GU/ID: uti's , on bactrim
chronically. Patient states he was on levoquin. Dc'd here. 5. Rheum:
allopurinol for gout , renally
dosed 6. Proph: heparin , PPI
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Please follow up with your primary care physician. Have your primary care physician refer you for
gastrointestinal follow up.
2. Please etake prilosec twice daily. Avoid late meals , caffeine , spicy
foods , chocolate , and mint
3. Notice the following med changes:
a.levoquin stopped
b. prilosec increased
No dictated summary
ENTERED BY: LARZELERE , GAYLE C. , M.D. ( SJ97 ) 10/18/06 @ 01:15 PM
****** END OF DISCHARGE ORDERS ******

Document id: 36

254826260 | PUO | 67733887 | | 6010668 | 9/6/2005 12:00:00 a.m. | hyponatremia and depression | | DIS | Admission Date: 11/10/2005 Report Status:

Discharge Date: 10/9/2005
****** DISCHARGE ORDERS ******
PREUETT , LATRICIA 002-54-26-6
Oeve Ave , A
Service: MED
DISCHARGE PATIENT ON: 1/5/05 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BOVA , DOUGLASS V. , M.D.
CODE STATUS:
No CPR / No defib / No intubation / No pressors /
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
SODIUM CHLORIDE 1 GM orally every day
NORVASC ( AMLODIPINE ) 5 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DEMECLOCYCLINE 300 MG orally twice a day
Food/Drug Interaction Instruction
Take 1 hour before or 2 hours after dairy products.
Take 3 hours before or 3 hours after Iron products.
Alert overridden: Override added on 4/9/05 by ALLEBACH , DIEDRE J VALENTINE , M.D.
POTENTIALLY SERIOUS INTERACTION: MAGNESIUM HYDROXIDE &
DEMECLOCYCLINE HCL Reason for override: monitor
GLYBURIDE 5 MG orally every day
DIET: Fluid restriction: 1.5L
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Holter in 1-2 weeks ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
depression
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
hyponatremia and depression
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
history of SCIATICA history of HIATEL HERNIA history of DUODENAL ULCERS BY
UGI SIADH with neg head MRI , nl TSH , nl cortisol ( 36 ) DM ( diabetes
mellitus ) HTN ( hypertension ) depression
( depression ) gilbert's syndrome diverticulosis ( diverticulosis )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
IVF , fluid restriction
BRIEF RESUME OF HOSPITAL COURSE:
HPI:76 year-old M with hx of SIADH ( neg with u in the past ) , DM ,
HTN and depression ( history of ECT ) with recent admission for hyponatremia ( Na
116 ) d/c'd home on 11/28 with Na of 132 , p/with depression , increased SOB ,
weakness , and presumed low Na. Per patient , he has not been feeling well
since d/c. Persist thirst , drinking 1 gallon per day , did take his
meds including demeclocycline. patient also feeling
depressed , lonely. ? SI , no plans. no fevers , ? chills. dull CP x 1
hour , resolved spontly. no cough. patient eval by psych in ED , felt not to
be suicidal , no inpt psych admit or 1:1 sitter
needed. VS: 98.6 , HR 99 , BP 126/64 , 100% RA. NAD , JVP 6cm ,
CTAB , RRR , no murmurs , abd soft , +BS , no pedal edema.
Labs: Na 127 , K 3.5 , Cr 0.8 , Tbili 1.9 , CK 356 , cardiac enzymes flat ,
osm 259 , urine Na <assay , osm 191 , WBC 21.4 63P , 4B , hct 36.4. U/A
neg for UTI.
CXR: no infiltrates.
*************Hospital Course****************
FEN: hyponatremia not significant. continue demeclocycline , 1.5L
fluid restrict , NS as IVF given low urine Na and
osm. Na 130 on day of discharge.
CV: ? hx of CP , no hx of CAD. EKG showed no new changes.
continue norvasc
Psych: patient quite depressed , not on antidepressed
( self d/c'd remeron in the past ) , social work , psych eval said that patient
most likely needs good outpt f/u , needs antidepressant as an outpt ( had
tried many in the past ). patient will be contacted by social workers in
Charv S patient will also see primary care physician re: antidepressant medications.
GI: constipated. Bowel regimen
ENDO: hx of DM , gluc 66 on admision. gluc improved on the following day.
RISS. PPx: PPI ,
lovenox
Dispo: physical therapy eval said that patient is able to walk around without difficulties. no
home physical therapy needed.
DNR/DNI
ADDITIONAL COMMENTS: for VNA: home safety eval , check Na on 2/23/05
for patient: please call Dr. Holter and make an appt to see her. you should
also be contacted by social workers at Meon Wellfor Pipebocock Medical Center .  please return to the
hospital if you develop severe fatigue or seizure.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
please follow up on patient's depression treatment , please follow up on patient's
sodium.
No dictated summary
ENTERED BY: ALLEBACH , DIEDRE JENNIFFER , M.D. ( PG59 ) 1/5/05 @ 12:00 PM
****** END OF DISCHARGE ORDERS ******

Document id: 37

028944445 | PUO | 26723331 | | 1667532 | 11/5/2005 12:00:00 a.m. | CEREBRAL BLEED | Unsigned | DIS | Admission Date: 11/5/2005 Report Status: Unsigned

Discharge Date: 9/11/2006
ATTENDING: VERNET , ROSANNE SOON
DATE OF DEATH: 1/26/06
PRINCIPAL DIAGNOSIS: Intracranial hemorrhage.
LIST OF PROBLEMS/DIAGNOSES:
1. Hypertension.
2. Diabetes type 2.
3. Atrial fibrillation.
4. COPD.
5. DVTs.
6. Carotid stenosis.
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old male
with a history of diabetes , hypertension , atrial fibrillation ,
not on Coumadin , and carotid stenosis , transferred from an
outside hospital to Pagham University Of with
intracranial hemorrhage. The patient noticed that about 3:15
p.m. , on 1/14/05 , the patient developed a sudden onset of
weakness on the left side and slurred speech. He was brought to
Norap Valley Hospital , where he was initially communicative and
denying headache , nausea , or vomiting. He was placed in the CT
scanner , and within 15 minutes , became less responsive. The
patient was intubated as a result. His systolic blood pressure
was between the 140s and 160s during this period , controlled with
total of 6 mg intravenous of Ativan and 10 mg intravenous of hydralazine. The
patient was then transferred to the Pagham University Of
Emergency Department. On arrival , the patient was posturing and
his systolic blood pressure was 220. He was treated with intravenous
labetalol , intravenous mannitol , 1 gm Dilantin , and 1 gm vancomycin. The
patient's blood pressure was controlled within 30 minutes.
Neurosurgery placed bilateral extraventricular drains in the
emergency department.
PAST MEDICAL HISTORY: Hypertension , diabetes type 2 , paroxysmal
atrial fibrillation , not on Coumadin , COPD , idiopathic DVTs , BPH ,
and bilateral carotid stenosis.
MEDICATIONS AT HOME: Prozac 40 mg orally daily , lisinopril 10
daily , NPH insulin 42 units every day before noon , 22 units every afternoon , Lopressor
100 twice a day , aspirin 325 mg daily , Advair , and Zocor 20 daily.
ALLERGIES: Sulfa and cephalosporins - rash.
SOCIAL HISTORY: The patient lives with his wife , 80-pack-year
smoking history , quit in 2002. The patient has three daughters.
PHYSICAL EXAMINATION ON ADMISSION TO THE ED: Neurological ,
limited by critical care and EVD placement. Mental status ,
unresponsive to sternal rub. Cranial nerves , pupils are
nonreactive at 3 mm. Motor/sensory , extensor posturing to
nailbed pressure in the upper extremities and triple flexion in
the lower extremities. DTRs , toes are upgoing bilaterally.
RADIOLOGICAL EXAMINATION: Head CT/CTA , 60 mL intracranial
hemorrhage in the right basal ganglia with intraventricular
hemorrhagic extension , and casting of the right lateral ventricle
and extension into the third and fourth ventricles. Compared to
the P Therford Hospital CT scan from 3 hours earlier , there was enlargement
of the intracranial hemorrhage and enlargement of the ventricles.
No AVM or aneurysm. Occluded right internal carotid artery that
reconstitutes at the level of the supraclinoid , which is old.
HOSPITAL COURSE: The patient remained unresponsive and intubated
during the entirety of this hospitalization. He was admitted to
the Neurological ICU following his emergency department care and
extraventricular drain placement by Neurosurgery in the emergency
department. He continued to have extraventricular drainage
throughout this hospital stay. Despite the efforts of draining
the patient's ventricles , there was no improvement in his
clinical exam. During the course of this hospitalization , the
patient did receive antibiotics ( Flagyl , levofloxacin , and
vancomycin ) for pneumonia. He received amiodarone and
beta-blockers for rapid heart rate. The patient unfortunately
did not respond to any of the above treatments , and remains
comatose throughout this hospitalization. After multiple family
discussions , the family decided to proceed with extubation on
9/13/06 .  The patient was made comfort measures only on that
afternoon. The patient was treated with a morphine infusion for
comfort. The patient expired at 2:06 a.m. , and the family was
notified.
eScription document: 3-8360825 CSSten Tel
CC: Glynis Margo Verbridge MD
Ressdar Medical Center , Derd News North
Dictated By: TRETT , JERI
Attending: VERNET , ROSANNE SOON
Dictation ID 7713987
D: 10/19/06
T: 8/7/06

Document id: 38

818177855 | PUO | 77991840 | | 5847015 | 5/3/2005 12:00:00 a.m. | orthostatic syncope | | DIS | Admission Date: 7/1/2005 Report Status:

Discharge Date: 11/26/2005
****** FINAL DISCHARGE ORDERS ******
SEARCH , ALBINA KATERINE 770-16-15-1
A Moines Cam
Service: MED
DISCHARGE PATIENT ON: 10/3/05 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HANSBERRY , SHAN ROBERTA , M.D.
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 81 MG orally every day
CALTRATE + D ( CALCIUM CARBONATE 1 , 500 MG ( 600 ... )
2 TAB orally twice a day
LIPITOR ( ATORVASTATIN ) 10 MG orally every day
Alert overridden: Override added on 10/3/05 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM Reason for override: md aware
METFORMIN 500 MG orally every day Starting IN a.m. ( 3/28 )
HYDROCHLOROTHIAZIDE 12.5 MG orally every day Starting IN a.m. ( 3/28 )
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
f/u with primary care physician ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
syncope
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
orthostatic syncope
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
orthostatic syncope
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
CC: I passed out"
HPI: 71 year-old female with pmhx htn , dm , cri brought to puo ED after
syncopal event 2/4/05 .  She had seen primary care physician with routine visit; later in
the evening she began to feel "woozy" at a friend's house. She
went to BR and had a loose BM shortly after which she became weak and
diaphoretic and passed out. ED eval revealed BP 150/71 , HR 54 and
otherwise unremarkable physical
exam. PMHX: as
above MEDS: see med list
below. ALL:
NKDA Social: lives alone , independent with adl's , no
etoh or tobacco. PE: 98.9 54 150/71
18 nad ,
alert heent: orally moist , flat
jvp heart: RRRS1__S2__ , no
murmurs Lungs: CTA
bilat abd:
benign LABS: troponin negative X
2 echo: normal LV function
overall EKG:
NSR Assessment: 71 year-old female with syncopal episode in
setting of recent fasting ( for bloodwork ) and loose BM. Likely
vasovagal episode post BM. No evidence of arrythmia or ACS. Concern
about respiratlry function ( and d dimer of 2000 ) was put to rest with
a low prob VQ scan. Planned to restart metformin and HCTZ 12.5 every day one day
post discharge as outpt with primary care physician follow up.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: STECK , GAYLORD A. , M.D. ( EB56 ) 10/3/05 @ 12:30 PM
****** END OF DISCHARGE ORDERS ******

Document id: 39

563635080 | PUO | 32361549 | | 5668913 | 10/29/2006 12:00:00 a.m. | L4-S1 LUMBAR SPINAL STENOSIS | Signed | DIS | Admission Date: 2/24/2006 Report Status: Signed

Discharge Date: 3/6/2006
ATTENDING: LEMMEN , BROOKE M.D.
PRINCIPAL DIAGNOSIS:
Spinal stenosis L4-S1.
PRINCIPAL PROCEDURE:
L4-S1 laminectomy.
DATE OF PROCEDURE:
10/28/06 .
HISTORY OF PRESENT ILLNESS:
The patient is a 76-year-old gentleman with a history of cardiac
transplant 15 years ago followed by the Cardiac Transplant
Service at Pagham University Of .  He presented to the
clinic with right buttock and leg pain. It has been
incapacitating to him and present since 5/15 .  He had a series
of epidural steroid injections that have not helped.
PAST MEDICAL HISTORY:
Cardiac transplant 15 years ago as stated above with chronic
immunosuppressives , history of gout , hypertension , renal
insufficiency.
ALLERGIES:
Penicillin.
PHYSICAL EXAMINATION:
The patient has a strongly positive straight leg raise on the
right with pain reproduced down the posterolateral thigh , leg and
into the dorsum plantar aspects of the foot. He has 4-/5
strength of the quads , tibials anterior and 3/5 strength in the
EHL and 4+/5 strength in the gastrocsoleus complex. He has a
sensation that is grossly intact to light touch throughout the
right lower extremity. He has diminished reflexes at patellar
tendon , Achilles tendon on the right.
IMAGING:
X-rays showed degenerative disc disease from L4 through S1 with
no significant listhesis. Outside MRI scan was reviewed and had
evidence of spinal stenosis at L4-L5 , a paracentral extruded disc
at L5-S1.
HOSPITAL COURSE:
The patient was cleared for surgical intervention. He was taken
to the operating room on 10/28/06 .  The procedure was
uncomplicated. Perioperative antibiotics were administrated. VD
boots were placed for DVT prophylaxis. The patient's
postoperative course was uncomplicated. No nausea or vomiting ,
no chest pain , and no shortness of breath. His diet was
advanced. He was afebrile and was tolerating regular diet. He
was transitioned to orally medications for pain without difficulty.
Physical therapy worked with the patient. He is out of bed
without much difficulty. His dressing was changed on
postoperative day #2 , and his wound continued to be clean and dry
with no evidence of infection throughout his hospital course. He
was cleared by physical therapy to be discharged home.
CONDITION ON DISCHARGE:
Stable.
DISCHARGE STATUS:
Home with Services.
DISCHARGE MEDICATIONS:
1. Tylenol 650 mg orally every 6 hours and as needed
2. Azathioprine 50 mg orally daily.
3. Calcitrol 0.25 mcg orally daily.
4. Codeine 15-30 mg orally every 4 hours as needed
5. Neoral cyclosporin 50 mg orally twice a day
6. Colace 100 mg orally twice a day
7. Lasix 80 mg orally daily.
8. Amaryl 3 mg orally every afternoon
9. Regular insulin sliding scale.
10. Potassium chloride slow release 10 mEq orally daily.
11. Labetalol 600 mg orally twice a day
12. Magnesium oxide 420 mg orally daily.
13. Rapamune 2 mg orally daily.
14. Sulfinpyrazone 200 mg orally twice a day
15. Timolol 0.5% one drop each eye every day before noon
FOLLOW-UP PLAN:
The patient is to keep the wound clean and dry until his follow
up. He is to follow up with Dr. Lemmen on 8/9/06 .  He is to
contact the office or the hospital if he has any worrisome
symptoms , worsening pain , fevers , etc.
eScription document: 8-8729663 EMSSten Tel
Dictated By: YAN , DERICK
Attending: LEMMEN , BROOKE
Dictation ID 1687977
D: 2/8/06
T: 2/8/06

Document id: 40

670224474 | PUO | 57155429 | | 1748541 | 3/10/2005 12:00:00 a.m. | OA , L knee | | DIS | Admission Date: 8/21/2005 Report Status:

Discharge Date: 8/13/2005
****** FINAL DISCHARGE ORDERS ******
SMOLINSKY , LARAE 070-17-73-5
S Wi Ester O Coing
Service: ORT
DISCHARGE PATIENT ON: 10/7/05 AT 11:00 a.m.
CONTINGENT UPON physical therapy clearance
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: FANIEL , GAYLENE , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
ALLOPURINOL 300 MG orally every day
Alert overridden: Override added on 2/4/05 by
WANTUCK , DELPHA , PA-C
SERIOUS INTERACTION: WARFARIN & ALLOPURINOL
Reason for override: will monitor
CALCIUM CARBONATE ( 500 MG ELEMENTAL CA++ ) 500 MG orally every day
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FERROUS SULFATE 325 MG orally three times a day
Food/Drug Interaction Instruction Avoid milk and antacid
HUMULIN N ( INSULIN NPH HUMAN ) 15 UNITS subcutaneously every day before noon and every afternoon
MVI ( MULTIVITAMINS ) 1 TAB orally every day
Override Notice: Override added on 2/4/05 by
WANTUCK , DELPHA , PA-C
on order for SIMVASTATIN orally ( ref # 46213778 )
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
SIMVASTATIN Reason for override: will be monitored
OXYCODONE 5-10 MG orally every 4 hours as needed Pain
METAMUCIL SUGAR FREE ( PSYLLIUM ( METAMUCIL ) SU... )
1 PACKET orally every day as needed Constipation
Instructions: may be given with the patients choice of
beverage
COUMADIN ( WARFARIN SODIUM ) 4 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: dose for 7/2/05 4mg , dose for 4/12 and
thereafter take as directed by anticoagulation
service , duration is 4 weeks
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Reason: Override added on 2/4/05 by WANTUCK , DELPHA , PA-C
on order for SIMVASTATIN orally ( ref # 46213778 )
POTENTIALLY SERIOUS INTERACTION: WARFARIN & SIMVASTATIN
Reason for override: will be monitored
Previous override information:
Override added on 2/4/05 by WANTUCK , DELPHA , PA-C
on order for ALLOPURINOL orally ( ref # 41656086 )
SERIOUS INTERACTION: WARFARIN & ALLOPURINOL
Reason for override: will monitor
NORVASC ( AMLODIPINE ) 10 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
METFORMIN 500 MG orally twice a day
LIPITOR ( ATORVASTATIN ) 20.0 MG orally every day
Alert overridden: Override added on 6/14/05 by :
POTENTIALLY SERIOUS INTERACTION: NIACIN , VIT. B-3 &
ATORVASTATIN CALCIUM
POTENTIALLY SERIOUS INTERACTION: WARFARIN & ATORVASTATIN
CALCIUM Reason for override: will be monitored
IRON SULFATE ( FERROUS SULFATE ) 325 MG orally every day
Food/Drug Interaction Instruction Avoid milk and antacid
DIET: House / ADA 2100 cals/dy
ACTIVITY: Full weight-bearing: please increase ROM as much as possible
FOLLOW UP APPOINTMENT( S ):
Dr. Rademan , 2/20/05 1:00XRAY , 2:00APT scheduled ,
Arrange INR to be drawn on 7/14/05 with f/u INR's to be drawn every
Monday/Thursday days. INR's will be followed by PUO Anticoagulation service , 592.004.9708
ALLERGY: LATEX
ADMIT DIAGNOSIS:
OA , L knee
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
OA , L knee
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
diabetes mellitus , hypertension , gout , atopic dermatitis
OPERATIONS AND PROCEDURES:
2/4/05 RADEMAN , CAITLIN , M.D.
RT TKR
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
9/1/05-KUB-negative
BRIEF RESUME OF HOSPITAL COURSE:
***Patient underwent elective LTKA for osteoarthritis on 2/4/05 .
Procedure went well and pain was controlled by epidural. Patient
received 1 unit of RBC's on DOS for HCT of 26. POD2 patient had a
distended abdomen and KUB was ordered. Results were negative and there
were no further signs of symptoms of an ileus. POD2
switched to orally pain meds and foley catheter removed. HCT on POD3 was
25.8 and patient was stable. Patient could not clear physical therapy protocol for
discharge on POD4 and subsequently was not dischrarged until POD5 in
stable condition. On POD#5 after two days of intravenous fluid his creatinine
improved to 1/3. His INR on the day of discharge was 1.5.
ADDITIONAL COMMENTS: Coumadin for DVT prophylaxis X3 weeks. Goal INR 1.5-2.5 , draw day after
discharge and every Monday/Thursday. Results & questions to PUO
Anticoagulation service , 083.782.7650. For wound-DSD changes , OTA when
dry. Remove staples on 8/21/05 .  Follow up with Dr. Rademan on 2/20/05 .
Weight bear as tolerated with upper extemity support.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Home care for blood draws-results and questions to PUO Anticoagulation
service , 083.782.7650. See instructions for complete detail.
Home care for wound-DSD changes , OTA when dry , remove sutures on
8/21/05 .
physical therapy-weight bear as tolerated with upper extremity support.
Follow up with Dr. Rademan on 2/20/05 .
No dictated summary
ENTERED BY: DEMOREST , MEGHAN O , M.D. ( PI820 ) 10/7/05 @ 02:38 PM
****** END OF DISCHARGE ORDERS ******

Document id: 41

473114375 | PUO | 60927482 | | 2954532 | 10/23/2004 12:00:00 a.m. | Failed Lt THR | | DIS | Admission Date: 10/23/2004 Report Status:

Discharge Date: 5/20/2004
****** DISCHARGE ORDERS ******
LEUENBERGER , BRIAN 014-98-92-6
Hen Blvd
Service: ORT
DISCHARGE PATIENT ON: 3/7/04 AT 11:00 a.m.
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: WAGNON , DENNA L. , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
MIACALCIN ( CALCITONIN-SALMON ) 1 SPRAY inhaled every day
Number of Doses Required ( approximate ): 4
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
MVI ( MULTIVITAMINS ) 1 TAB orally every day
PREDNISONE 20 MG orally every day before noon
COUMADIN ( WARFARIN SODIUM ) 3 MG orally every afternoon
Starting Today ( 9/24 )
Instructions: Or as directed by the anticoagulation service
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 2/10/04 by
KNUTESON , PRECIOUS D. , M.D.
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
WARFARIN Reason for override: every day inr
PAXIL ( PAROXETINE ) 20 MG orally every day
TRICOR ( FENOFIBRATE ) 320 MG orally every day Starting IN a.m. ( 9/17 )
Override Notice: Override added on 2/10/04 by
KNUTESON , PRECIOUS D. , M.D.
on order for COUMADIN orally ( ref # 00994206 )
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
WARFARIN Reason for override: every day inr
Previous override information:
Override added on 2/18/04 by KNUTESON , PRECIOUS D. , M.D.
on order for COUMADIN orally ( ref # 37006506 )
POTENTIALLY SERIOUS INTERACTION: FENOFIBRATE , MICRONIZED &
WARFARIN Reason for override: every day inr
Previous override information:
Override added on 10/11/04 by KNUTESON , PRECIOUS D. , M.D.
POTENTIALLY SERIOUS INTERACTION: WARFARIN & FENOFIBRATE ,
MICRONIZED Reason for override: inr
Number of Doses Required ( approximate ): 6
ZELNORM ( TEGASEROD ) 12 MG orally twice a day
Number of Doses Required ( approximate ): 4
LANTUS INSULIN 150 UNITS subcutaneously every bedtime
PRILOSEC ( OMEPRAZOLE ) 20 MG orally twice a day
PERCOCET 1-2 TAB orally every 4 hours as needed Pain
ZESTRIL ( LISINOPRIL ) 20 MG orally twice a day
DIET: House / ADA 1800 cals/dy
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr Wagnon 9/25/05 Xray at 10:00am Appt at 11:00am 8/7/05 scheduled ,
Arrange INR to be drawn on 11/1/04 with f/u INR's to be drawn every
Mon/Thurs days. INR's will be followed by PUO Anticoagulation Service
ALLERGY: Sulfa
ADMIT DIAGNOSIS:
Failed Lt THR
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Failed Lt THR
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
SLE , IDDM , HTN , Depression , GERD
OPERATIONS AND PROCEDURES:
10/11/04 WAGNON , DENNA L. , M.D.
REVISION OF L. HIP REPLACEMENT
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
N/A
BRIEF RESUME OF HOSPITAL COURSE:
patient underwent a revision Lt THR on 10/11/04 .  The patient tolerated the
procedure well and in the PACU was tachycardic with rate of 150 and
SBP< 90. Medicine was consulted recommended transfer to a monitored bed
and to check serial TnI's. patient's troponin levels bumped and medicine
suggested covering patient with beta blockade , obtaining an echo , and
transfusing with 1 unit of PRBCs to maintain a Hct >30. patient was
asx and Medicine continued to follow the patient. POD 1 Zestril was
d/c'd and electrolytes repleted. intravenous hydrocortisone was d/c'd. Troponin
leak was felt to be likely from cardiac strain , demand related. Through
the remainder of her hospitalization her rate was well controled.
Standard care with prophylactic intravenous abx and TEDS/Coumadin/P-boots for DVT
prophylaxis. Wound clean clean and healing. Inta-operative cx
grewalpha heme strep in liquid medium only. The path was reviewed
and this was felt to represent a contaminent. Echo was WNL and
telemetry was d/c'd on POD 2. patient progressed well with physical therapy , and was
deemed safe for discharge home with services and support of parents on
POD 3.
ADDITIONAL COMMENTS: Dry sterile dressing daily. The wound may be left open to air when
dry. You may shower when the wound is dry X 72 hrs , Blood draws for
physical therapy/INR the day after discharge then every Mon/Thurs with results called to
the PUO Anticoagulation Service at 988-605-5355 ext 1. Goal INR is
1.5-2.5;DVT prophylaxis is planned X 6 weeks. Any outpatient
anticoagulation issues or action values should be called to the
Anticoagulation Service.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Blood draws for physical therapy/INR the day after discharge then every Mon/Thurs with
results called to 988-605-5355 ext 9 for outpatient anticoagulation
management
Home services for physical therapy , nursing/wound assessment , and phlebotomy
Follow up with Dr Wagnon as scheduled
No dictated summary
ENTERED BY: SCOVEL , DULCIE , PA-C ( XP60 ) 3/7/04 @ 12:05 PM
****** END OF DISCHARGE ORDERS ******

Document id: 42

009083719 | PUO | 04731180 | | 318684 | 6/5/2001 12:00:00 a.m. | atypical chest pain | | DIS | Admission Date: 9/10/2001 Report Status:

Discharge Date: 9/21/2001
****** DISCHARGE ORDERS ******
LIEBECK , KELSI 057-82-87-9
Sta La Nahamp
Service: MED
DISCHARGE PATIENT ON: 2/16/01 AT 12:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DICKHAUT , SIOBHAN CARY , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
XANAX ( ALPRAZOLAM ) 0.25 MG orally every 6 hours as needed anxiety
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Override Notice: Override added on 11/9/01 by
SELIA , DIONNE T. , M.D.
on order for COUMADIN orally ( ref # 58008963 )
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
Reason for override: md aware
CLONIDINE ( CLONIDINE HCL ) 2.5 MG TP Q168H
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LEVOXYL ( LEVOTHYROXINE SODIUM ) 25 MCG orally every day
Override Notice: Override added on 11/9/01 by
SELIA , DIONNE T. , M.D.
on order for COUMADIN orally ( ref # 58008963 )
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
Reason for override: md aware
LOPRESSOR ( METOPROLOL TARTRATE ) 50 MG orally three times a day
Starting Today ( 4/06 )
COUMADIN ( WARFARIN SODIUM ) 3 MG orally every bedtime
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 11/9/01 by
SELIA , DIONNE T. , M.D.
POTENTIALLY SERIOUS INTERACTION: ASPIRIN & WARFARIN
SERIOUS INTERACTION: LEVOTHYROXINE SODIUM & WARFARIN
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
POTENTIALLY SERIOUS INTERACTION: CELECOXIB & WARFARIN
Reason for override: md aware
ZOCOR ( SIMVASTATIN ) 10 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 11/9/01 by
SELIA , DIONNE T. , M.D.
on order for COUMADIN orally ( ref # 58008963 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: md aware
CELEBREX ( CELECOXIB ) 200 MG orally twice a day
Food/Drug Interaction Instruction Take with food
Override Notice: Override added on 11/9/01 by
SELIA , DIONNE T. , M.D.
on order for COUMADIN orally ( ref # 58008963 )
POTENTIALLY SERIOUS INTERACTION: CELECOXIB & WARFARIN
Reason for override: md aware
PRILOSEC ( OMEPRAZOLE ) 20 MG orally twice a day
MEDROXYPROGESTERONE 5 MG orally every day
ESTRADERM ( ESTRADIOL ) 0.05 MG TP every 72 hours
DIET: House / Low chol/low sat. fat
RETURN TO WORK: Not Applicable
FOLLOW UP APPOINTMENT( S ):
Dr. Deiss ,
ALLERGY: Tylenol ( acetaminophen ) , Zantac ( ranitidine hcl )
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
atypical chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
ATYPICAL cHEST PAIN
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
BRIEF RESUME OF HOSPITAL COURSE:
55 year-old female with hx of HTN , Hyperchol and previous admits for atypical
chest pain all of which have been neg for MI or PE , presented to ED
with hx SOB , diaphoresis and CP that radiated to left neck and arm that
lasted for only several minutes. patient CXR was neg , cardiac enzymes were
neg , Spiral CT neg for PE , and no ischemic changes on EKG , with no
telemetry events noted. patient is discharged in stable condition.
ADDITIONAL COMMENTS: Please call primary care physician or go to ED if shortness of breath or chest pain
develop or worsen.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: COCOMAZZI , REA , M.D. , Q.B.TH ( DE67 ) 2/16/01 @ 12:42 PM
****** END OF DISCHARGE ORDERS ******

Document id: 43

259895307 | PUO | 80528967 | | 3648858 | 2/28/2004 12:00:00 a.m. | NSTEMI | | DIS | Admission Date: 2/28/2004 Report Status:

Discharge Date: 9/22/2004
****** DISCHARGE ORDERS ******
SWARTZBAUGH , MALCOLM 191-06-56-4
Font Bo Vi
Service: ETMCH
DISCHARGE PATIENT ON: 10/22/04 AT 04:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: STEARN , JENNY L. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ENTERIC COATED ASA ( ASPIRIN ENTERIC COATED )
325 MG orally every day
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual Q5MIN X 2 doses
as needed Chest Pain HOLD IF: sbp less than 100 mmHg
Instructions: Do not administer if receiving intravenous
nitroglycerin.
PREDNISONE 60 MG orally every day before noon
TRAZODONE 50 MG orally HS as needed Insomnia
ZOLOFT ( SERTRALINE ) 50 MG orally every day
ZOCOR ( SIMVASTATIN ) 40 MG orally every bedtime Starting Today ( 3/7 )
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
PLAVIX ( CLOPIDOGREL ) 75 MG orally every day
Instructions: Begin Plavix tomorrow if a loading dose was
administered on the day of the procedure.
ADVAIR DISKUS 250/50 ( FLUTICASONE PROPIONATE/... )
1 PUFF inhaled twice a day
DILTIAZEM CD 120 MG orally every day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
HYDROCHLOROTHIAZIDE 25 MG orally every day
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr Pederzani 2-4 weeks ( you will receive a phone call with time from Dr Vorhees office ) ,
Primary care physician 1-2 weeks ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
NSTEMI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
NSTEMI
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
OBESITY RAD MULT TAPERS asthma
( asthma ) OSA ( sleep apnea ) ?diabetes ( ? diabetes mellitus )
OPERATIONS AND PROCEDURES:
None
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Cardiac catheterization with stent placement to the LAD.
BRIEF RESUME OF HOSPITAL COURSE:
45yoF with obesity , htn , asthma p/with chest pressure of new onset while
teaching class today. Was assoc with sob and diaphoresis. Was
admitted to ED obs , had negative a set , but tni on b set=2.
ECG reportedly without change but did in fact have twi in precordial
leads. patient developed renewed chest pain on floor assoc with n/v , and
had emergent cath which revealed lad lesion which
was stented with drug-eluting stent.
+++++++++++++++++++++++++++++++++++++++++++++++++
HOSP COURSE BY SYTEMS
1 ) CV: isch-history of stenting to LAD for NSTEMI
-cont asa , statin , plavix
-held hctz but instructed patient to re-start this as outpt.
-initially tx patient with bb , but this seemed to exacerbate her asthma , so
this was switched to diltiazem. Norvasc was stopped
-patient received integrilin x 18h post cath
2 ) Pulm: asthma
-on prednisone 60 for recent exacerbation , will taper after d/c
-cont inhalers
3 ) Psych: cont zoloft , ativan
patient will be discharged to home in stable condition to follow up with her
pcp and her cardiologist.
ADDITIONAL COMMENTS: You have new medicines: diltiazem SR 120 mg a day , plavix 75 mg a day ,
zocor 40 mg a day , aspirin 325 mg a day. Continue your
hydrochlorothiazide. Stop taking norvasc. If needed take
nitroglycerin tablets under your tongue for chest pain ( follow
directions on prescription ). If you have chest pains , shortness of
breath , or any other concerns please call your doctor or come to the
emergency room. Taper your prednisone as instructed on prescription
( and discuss this with your primary care physician )
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Follow up with your primary care physician in 1-2 weeks.
Follow up with Dr Pederzani ( cardiology ) in 2-4 weeks.
No dictated summary
ENTERED BY: JACOBSOHN , JAMA J. , M.D. ( TY87 ) 10/22/04 @ 02:33 PM
****** END OF DISCHARGE ORDERS ******

Document id: 44

231980943 | PUO | 45274139 | | 628660 | 10/6/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 1/28/1990 Report Status: Unsigned

Discharge Date: 10/16/1990
HISTORY OF PRESENT ILLNESS: Patient is a 40 year old female with a
history of cholelithiasis who was
recently discharged from Pagham University Of on November ,
l990 after an incisional hernia repair who , soon after , noted onset
of right upper quadrant pain , vomiting , and fever and was
readmitted with an ultrasound at that time showing two 8-9 mm
gallstones in the right upper quadrant. Patient was treated with
intravenous antibiotics but deferred surgery at that time and was
discharged home after defervescing. Approximately six weeks prior
to admission , the patient was seen in the Emergency Ward for
recurrent right upper quadrant pain without nausea , vomiting , or
fever. The patient then was subsequently seen by Dr. Haraguchi in the
Uass Goldman Valley Medical Center and a cholecystectomy was scheduled on a
routine basis. PAST MEDICAL HISTORY: Non-contributory. PAST
SURGICAL HISTORY: Includes a cesarean section in l988 and a
ventral hernia repair in October of l990. CURRENT MEDICATIONS:
Naprosyn as needed for right upper quadrant pain. ALLERGIES:
Include Penicillin which gives her a rash and Compazine which leads
to a dystonic reaction. SOCIAL HISTORY: She does not smoke or
drink.
PHYSICAL EXAMINATION: Patient was afebrile with stable vital
signs. SKIN: Scattered skin tags on her
trunk. NODES: Negative. HEAD/NECK: Benign. BREASTS: Without
masses , tenderness , or axillary adenopathy. LUNGS: Clear to
auscultation. HEART: Regular rate and rhythm with no murmurs ,
gallops , or rubs. PULSES: 2+ bilaterally. ABDOMEN: Obese ,
positive bowel sounds , and non-tender with a small fascial defect
at the umbilicus and a well healed midline scar. NEUROLOGICAL:
Non-focal.
LABORATORY EXAMINATION: Her EKG showed normal sinus rhythm at 7l
beats per minute with an axis of positive
40 degrees , normal intervals , and no ischemic changes. Her chest
X-Ray was clear. Her electrolytes were all within normal limits ,
her BUN was 22 , and her creatinine was l.0. Her glucose was 88.
Her white count was 6.4 , her hematocrit was 33.l , and her platelets
were 259. Her physical therapy was l2.3 and her PTT was 29.9. Her urinalysis
showed 3-4 white blood cells and l+ bacteria.
HOSPITAL COURSE: The patient arrived the same day as her surgery
and was taken directly to the Operating Room.
Patient was placed under general anesthesia and her intubation was
particularly difficult secondary to obesity requiring fiberoptic
intubation and Anesthesia elected , at this time , to place both an
A-line and a central venous access in order to be able to optimally
monitor this difficult obese patient. Patient then underwent a
very uncomplicated cholecystectomy at which time a distended
gallbladder with several stones was found. The patient was taken
to the Recovery Room in stable condition after being extubated. Her
O2 saturation on 40% facemask was 96% in the Recovery Room and both
her nasogastric tube and Foley tube were removed without incident.
Her A-line was also removed before transfer to the floor but her
central line remained in place until the following day. Patient
received two doses of Gentamicin as prophylaxis post-operatively.
The patient had an unremarkable post-operative course with a
post-operative hematocrit of 3l.5 and white count of 8.4. Her diet
was slowly advanced and she remained afebrile with good oxygen
saturations on room air and good urine output.
DISOSITION: She was discharged to home on post-operative day
number five with an appointment to follow-up in the
Uass Goldman Valley Medical Center on Thursday , January , for a wound check.
________________________________ SD321/9795
NADA D. LANGHOUT , JR , M.D. SF2 D: 9/27/90
Batch: 8589 Report: S1567M27 T: 10/2/90
Dictated By: CARMON BOSHERS , M.D.

Document id: 45

076292010 | PUO | 42300636 | | 1403118 | 8/10/2003 12:00:00 a.m. | colonic microperforation , afib | | DIS | Admission Date: 8/17/2003 Report Status:

Discharge Date: 1/17/2003
****** DISCHARGE ORDERS ******
BRETH , BRANDY T 114-82-80-8
Lie Rira
Service: MED
DISCHARGE PATIENT ON: 3/5/03 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: IN , DERICK T , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
FESO4 ( FERROUS SULFATE ) 300 MG orally twice a day
Starting IN a.m. ( 8/3 ) Food/Drug Interaction Instruction
Avoid milk and antacid
FOLATE ( FOLIC ACID ) 1 MG orally every day
SYNTHROID ( LEVOTHYROXINE SODIUM ) 100 MCG orally every day
PREDNISONE 5 MG orally every day before noon
ZOCOR ( SIMVASTATIN ) 20 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Override Notice: Override added on 9/22/03 by
MOLANDS , MARIETTE ALEISHA , M.D.
on order for NEORAL orally ( ref # 31963625 )
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & CYCLOSPORINE
Reason for override: will monitor
NEORAL ( CYCLOSPORINE MICRO ( NEORAL ) ) 100 MG orally twice a day
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
Give with meals
Override Notice: Override added on 9/22/03 by
MOLANDS , MARIETTE ALEISHA , M.D.
on order for LOSARTAN orally ( ref # 91421046 )
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE & LOSARTAN
POTASSIUM Reason for override: will monitor
Previous override information:
Override added on 9/22/03 by MOLANDS , MARIETTE ALEISHA , M.D.
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & CYCLOSPORINE
Reason for override: will monitor
LOSARTAN 50 MG orally every day
Alert overridden: Override added on 9/22/03 by
MOLANDS , MARIETTE ALEISHA , M.D.
POTENTIALLY SERIOUS INTERACTION: CYCLOSPORINE & LOSARTAN
POTASSIUM Reason for override: will monitor
Number of Doses Required ( approximate ): 3
ATENOLOL 25 MG orally every day
PRILOSEC ( OMEPRAZOLE ) 20 MG orally every day
AMIODARONE 400 MG orally twice a day
Instructions: 400 twice a day x 6 days , then 400 every day x 1 week , then
200 every day Alert overridden: Override added on 3/5/03 by :
POTENTIALLY SERIOUS INTERACTION: LEVOFLOXACIN & AMIODARONE
HCL Reason for override: aware
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
Starting Today ( 8/25 ) Instructions: To start on 4/21 .
FLAGYL ( METRONIDAZOLE ) 500 MG orally three times a day X 2 Days
Food/Drug Interaction Instruction Take with food
LEVOFLOXACIN 500 MG orally every day X 2 Days
Starting Today ( 8/25 ) Food/Drug Interaction Instruction
Administer iron products a minimum of 2 hours before or
after a levofloxacin or ciprofloxacin dose dose
If on tube feeds , please cycle ( hold 1 heart rate before to 2 heart rate
after ) Take 2 hours before or 2 hours after dairy products.
Alert overridden: Override added on 3/5/03 by :
POTENTIALLY SERIOUS INTERACTION: AMIODARONE HCL &
LEVOFLOXACIN Reason for override: aware
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Larose ( cardiology ) 6/7/03 scheduled ,
Gastroenterology- Dr. Sampey , call for appointment. ,
ALLERGY: Iv contrast dyes , Codeine , Penicillins , Erythromycins ,
Morphine , Demerol
ADMIT DIAGNOSIS:
Aspiration PNA
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
colonic microperforation , afib
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
cad ( coronary artery disease ) hodgkin ( Hodgkins disease ) renal
transplant ( kidney transplant ) htn
( hypertension ) history of appy ( history of appendectomy ) history of A fib ( history of atrial
fibrillation ) hypothyroidism ( hypothyroidism ) polyarteritis
OPERATIONS AND PROCEDURES:
Colonoscopy under general anesthesia.
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
none
BRIEF RESUME OF HOSPITAL COURSE:
74 year-old woman in remission from Hodgkin's Lymphoma
and history of renal transplant( 1/20 ) who p/with hypoxia , low grade fever in
setting of colonoscopy under general anesthesia. patient had PET scan on
4/3 which showed uptake in asc colon and hep
flexure concerning for malignancy. CT colonoscopy
showed 1.6 les in desc colon and colonoscopy under
GA performed due to difficulty of going beyond
hep flexure. patient had hypoxia to 80s when
awakening from anesthesia. Temp to 101.1. CXR showed
?LLL opacity. Thought to be likely Pneumonitis vs. asp PNA. In Pacu
patient also had EKG changes , TWIs and ? BBB assoc
with HR70s-80s. EKGs resolved when rate in 60s.
Physical Exam revealed AOOx3 woman in NAD. PERRL. No carotid bruits.
Cardiac exam remarkable for RRR , 2/6 murmur at RUSB. There are
crackles at LL base to mid lung field. Abd exam there is
rebound and invol guarding. Tenderness in epigastric
and suprapubic area. +BS. No hepatomegaly.
Labs significant for HCt 24 from baseline of 30 , Cr
1.9 from baseline of 1.6. Cardiac enzymes were flat.
HOSPITAL COURSE:****************
1. Pulm-On floor patient's oxygenation improved within one day to 96% on RA
Likely aspiration , but final read on
CXR shows no infiltrate/opacity. Levo/Flagyl given empirically x 5days
though she remained afeb.
2. CV-patient has history of MI , RCA stent , mod AS. Low Hct and EKG changes
concerning for
myocardial injury. Her cardiac enzymes were negative after the initial
hypoxic episode , and EKG changes resolved. Transfused 2u PRBCs. On
4/23 she had Afib with RVR to 130s with chest arm pain which is her
anginal equivalent. ECG with rate related ischemia ST depression
V5-6 , L. +Minimal troponin leak to 0.19 , which subseq downtrended
with nl CK. She was init treated with lopressor 5mg
intravenous but had hypotension to 80's which resolved quickly with IVF. She was
eventually rate controlled with dilt drip. She returned to sinus
rhythm within the day. Cards c/s'd
and recommended amio load. She had PFT's , LFT's and TFT's prior to
d/c. Plan to follow up with Dr. Larose . Consider anticoagulation for
PAF , this is at least 2nd episode. patient to restart ecasa 5d p colonosco
py.
2. GI-patient had abd exam concerning for focal peritoneal
irritation. It is likely that she had a microperforation during
colonoscopy as CT showed fluid in pelvis and she had Hct drop
requiring 2U pRBC. Her exam improved , and she was tolerating orally well
at the time of discharge. She has been afeb and well appearing for
several days prior to d/c. Plan to complete 5d abx. As per Dr. Sampey
her colonoscopy was complex , and she had polypectomy of 2.5 cm polyp.
Path is pending. If + for cancer , the base looked "clean" , so may be
feasible to re-scope her for surveillance at a later time , as per GI.
3. HEME- Hct after colonoscopy went to
24 ( baseline 30 ); post-transfusion HCt of 30.
5. history of Renal transplant. Continuing meds.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
No dictated summary
ENTERED BY: HANSBERRY , SHAN ROBERTA , M.D. ( WD511 ) 3/5/03 @ 05:24 PM
****** END OF DISCHARGE ORDERS ******

Document id: 46

475612587 | PUO | 46047117 | | 7447039 | 1/5/2004 12:00:00 a.m. | depression , anxiety | | DIS | Admission Date: 1/5/2004 Report Status:

Discharge Date: 3/21/2004
****** DISCHARGE ORDERS ******
PICARDO , ASHELY 918-55-83-3
I
Service: MED
DISCHARGE PATIENT ON: 7/20/04 AT 03:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: MUHLSTEIN , GERARD , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
PROZAC ( FLUOXETINE HCL ) 20 MG orally every day
GLUCOTROL XL ( GLIPIZIDE XL ) 10 MG orally every day before noon
NIFEDIPINE ( EXTENDED RELEASE ) ( NIFEDIPINE ( sublingual... )
90 MG orally every day HOLD IF: SBP < 100
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ATENOLOL 50 MG orally every day
LISINOPRIL 20 MG orally every day
Alert overridden: Override added on 4/23/04 by :
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: will monitor
THIAMINE HCL 100 MG orally every day
FOLATE ( FOLIC ACID ) 1 MG orally every day
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally every day
Alert overridden: Override added on 7/20/04 by :
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & NIACIN ,
VIT. B-3 Reason for override: WILL MONITOR
DIET: House / Low chol/low sat. fat
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Dr. Kleinsasser ( primary care physician ) 10/27/04 scheduled ,
Dr. Augustine Milholland ( Psych , Na Tallton Sti ) 10/8/04 scheduled ,
Dr. Vannorman ( Neurology PUO ) 7/27/04 scheduled ,
ALLERGY: Penicillins , Erythromycins , Aspirin
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
depression , anxiety
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
tobacco abuse htn lbbb since 1989 palpitations
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
NONE
BRIEF RESUME OF HOSPITAL COURSE:
53 year-old F with history of nonobstructive CAD , HTN , DM , very depressed and
anxious since death of daughter 10/4 , p/with 1-2 wks of intermittent L
arm pain and L leg pain , also with intermittent sharp CP worse with deep
breath , + tightness , getting worse. CP orginiates in neck and arms
and then goes to chest. + diaphoresis , + palpitations , some SOB with
one flight of stairs , no orthopnea. Pain similar to CP prior to cath
in '00 ( showing non-obstructive CAD ). Also depressed and anxious
since daughter committed suicide , occasionally also has SI , + PLAN.
Thinks pain may be related to anxiety. In ED got sublingual NTG with relief ,
first set of cardiac enz neg.
PMH: CAD , HTN , DM , Deperssion
ALL: PCN , ASA , Erythromycin
MEDS: Atenolol , Glucotrol XL , Lisinopril , Prozac , Nifedipine
SHX: history of suicide of only daughter 10/4 , lives in friend's house , 1/2
ppd x 30 yrs , 1/2 pint vodka per day , history of IVDU 30 yrs ago
FHX: Mom with MI in 50s
LABS: CK 232 , MB 3.0 , TnI < assay HCT 33.8 , MCV 104 RDW 15
EKG: NSR at 79 , old LBBB , QRS 160 , borderline LVH with strain pattern.
unchanged from old
Serum Tox + ALC ( 153 )
PE: T97/2 HR 97 , RR 20 , BP 110/96 , 98% RA.
NAD , ETOH odor. NC/AT EOMI. CTAB. RRR , S1/S2 , CP reproduced with mech
pressure. Abd + BS S/nT/nd Ext WWP , 4/5 L hip flexsion , no C/C/E
IMPRESSION: 53 year-old F with CP likely non cardiac , first set enz neg. ?
costochondritis vs. psych component.
CV: Ruling out for MI given DM , low likelyhood. ASA allergy.
Continued BB/ACE/CCB. On tele during ruleout with no acute events
. Continue BP meds.
PSYCH: Required 1:1 sitter given SI. Was quiet throughout hospital
course , not actively suicidal. Continued prozac. Ativan as needed
withdrwal. Psych felt may benefit from Outpatient psych follow-up.
NEURO: ? L hip weakness , felt to be 2/2 peripheral neuropathy. Getting
head CT to r/o stroke --> HEAD CT was negative. Will need outpatient
neuro f/u with lumbar/thoracic MRI ( see MSK below ).
MSK: L shoulder film showed only degenerative changes , no fracture.
Lumbar and Thoracic MRI for ? spinal stenosis given chronic L shoulder
and LLE pain is pending.
FEN: Lytes were repleted as needed , also geting Thiamine , folate , MVI.
Prophy: Lovenox , Nexium
++++
DISPO: DISCHARGED ON HER REGULAR HOME MEDS. WILL NEED FOLLOW UP ON
THORACIC AND LUMBAR MRI. HAS APPT WITH primary care physician ON 4/9 .  OUTPT PSYCH
FOLLOW UP WITH DR. AUGUSTINE MILHOLLAND 10/23 11AM. OUTPT NEURO F/U
WITH DR. VANNORMAN 5/25 2PM.
ADDITIONAL COMMENTS: 1. PLEASE TAKE ALL OF YOUR REGULAR MEDICINES + MULTIVITAMINS , THIAMIN
E , FOLATE. IF THE DOSE ABOVE DOES NOT MATCH YOUR HOME MEDS AND DOSES ,
PLEASE TAKE YOUR HOME MEDS & DOSES.
2. PLEASE FOLLOW-UP WITH YOUR PRIMARY CARE PHYSICIAN , THE PSYCHIATRIST
TOMORROW , AND THE NEUROLOGIST ON 5/25 .
DISCHARGE CONDITION: Stable
TO DO/PLAN:
FOLLOW UP with Psych re. depression , anxiety , SI.
FOLLOW UP WITH Neuro re. L hip weakness , will need to follow-up
THORACIC AND LUMBAR MRI results.
No dictated summary
ENTERED BY: HENDY , CLARETHA , M.D. , PH.D. ( TD18 ) 7/20/04 @ 02:45 PM
****** END OF DISCHARGE ORDERS ******

Document id: 47

106565366 | PUO | 86025167 | | 100667 | 6/16/2001 12:00:00 a.m. | Infected R THR | | DIS | Admission Date: 6/16/2001 Report Status:

Discharge Date: 6/19/2001
****** DISCHARGE ORDERS ******
VIANA , BELLE A 436-75-25-7
Au
Service: ORT
DISCHARGE PATIENT ON: 1/29/01 AT 03:00 PM
CONTINGENT UPON Eval by Cardiology
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BELIZ , MEREDITH , M.D.
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed headache
VENTOLIN ( ALBUTEROL INHALER ) 1-2 PUFF inhaled four times a day
as needed sob/wheeze
ECASA ( ASPIRIN ENTERIC COATED ) 325 MG orally every day
ATENOLOL 25 MG orally every day Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
CEFTRIAXONE 2 , 000 MG intravenous every day
Number of Doses Required ( approximate ): 2
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
ENALAPRIL ( ENALAPRIL MALEATE ) 2.5 MG orally every day
PERCOCET 1-2 TAB orally every 4 hours as needed pain
ZOCOR ( SIMVASTATIN ) 5 MG orally every bedtime
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
ISOSORBIDE MONONITRATE 30 MG orally every day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food ) Number of Doses Required ( approximate ): 15
NEXIUM ( ESOMEPRAZOLE ) 20 MG orally every day
DIET: No Restrictions
RETURN TO WORK: after eval by Dr Beliz
FOLLOW UP APPOINTMENT( S ):
Dr Beliz 9/10/01 , PUO pre-admit for OR I&D/removal hardware. 9/10/01 scheduled ,
ALLERGY: Shellfish , Morphine
ADMIT DIAGNOSIS:
Infected R THR
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Infected R THR
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hodgkins lymphoma ( Hodgkins disease ) Asthma ( asthma ) R total hip
replacement ( total hip replacement ) septic joint ( total hip
replacement ) non Q wave MI; Extensive CAD.
OPERATIONS AND PROCEDURES:
CT-guided aspiration R hip per Radiology 10/26/01 .
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
intravenous Abx
BRIEF RESUME OF HOSPITAL COURSE:
Admitted from office 10/26/01 for infected L THR. Aspiration
demonstrated purulent material. Started on Ceftriaxone per ID consult
recs. MIC to both PCN and Ceftriaxone pending. MRI of pelvis completed
6/27/01 as pre-op eval. TU Cardiology was consulted for pre-op
clearance given extensive history of cardiomyopathy and unstentable CAD per
last cardiac cath 3/5 .  On further d/with physical therapy , he was adament about being
allowed to be D/C home on Abx for July holiday. Given that his
clinical picture was much improved on antibiotics , both Dr Beliz and ID
MD agreed to this on provision that he return immediately for any
evidence of progressing infection. His R hip pain and exam were much
improved by time of discharge. Will plan for intravenous lon line to be placed
prior to D/C for home dosing of every day Ceftriaxone. ID to be re-consulted
on admission post-op 1/2 for re-eval of abx choice. By that time it
is presumed that the MIC for PCN/CTX will be available for ascertation
of proper long-term Abx care.
ADDITIONAL COMMENTS: Return immediately for increasing temps/shaking chills/pain at R hip.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. D/C home with services for every day CTX dosing.
2. intravenous long line placement.
3. Re-admission for removal of infected hardware and spacer placement
9/10/01 .
4. intravenous Ceftriaxone per VNA 2 Gr intravenous every day for 4/18/01 .
No dictated summary
ENTERED BY: BARRANCA , SONNY M. , M.D. ( MN74 ) 1/29/01 @ 09:20 a.m.
****** END OF DISCHARGE ORDERS ******

Document id: 48

838440387 | PUO | 59556390 | | 8559314 | 11/24/2007 12:00:00 a.m. | same | | DIS | Admission Date: 8/17/2007 Report Status:

Discharge Date: 8/9/2007
****** FINAL DISCHARGE ORDERS ******
ROTHMAN , BAILEY 329-84-06-2
Newvi Dr
Service: MED
DISCHARGE PATIENT ON: 1/27/07 AT 04:00 PM
CONTINGENT UPON SNF/rehab
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: GUMINA , MARJORY SHELA , M.D.
CODE STATUS:
Full code
DISPOSITION: Skilled Nursing Facility
MEDICATIONS ON ADMISSION:
1. ACETYLSALICYLIC ACID 325 MG orally every day
2. ATORVASTATIN 80 MG orally every day
3. DOCUSATE SODIUM 100 MG orally twice a day
4. ESOMEPRAZOLE 40 MG orally every day
5. LACTULOSE 30 MILLILITERS orally twice a day
6. LISINOPRIL 10 MG orally twice a day
7. METOPROLOL SUCCINATE EXTENDED RELEASE 25 MG orally every day
8. CLOPIDOGREL 75 MG orally every day
9. GLIPIZIDE 2.5 MG orally every day
MEDICATIONS ON DISCHARGE:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ACETYLSALICYLIC ACID 325 MG orally DAILY
Starting IN a.m. ( 7/1 )
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
Override Notice: Override added on 7/9/07 by
SOSAYA , AMBERLY , M.D. , PH.D.
on order for MULTIVITAMIN THERAPEUTIC orally ( ref #
911430519 )
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: mda
DULCOLAX RECTAL ( BISACODYL RECTAL ) 10 MG PR DAILY
as needed Constipation
CELEXA ( CITALOPRAM ) 30 MG orally DAILY
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
LOVENOX ( ENOXAPARIN ) 40 MG subcutaneously DAILY
Starting Today ( 3/23 )
Instructions: Continue until patient going home , then stop
FERROUS SULFATE 325 MG orally three times a day Starting Today ( 3/23 )
Instructions: PLEASE MAKE SURE patient getting a very adequate
bowel regimen ( given constipation on presentation ) and
constipation while taking iron. Please make sure
getting colace , senna scheduled , and MOM/lactulose to
facilitate a bm every day. Food/Drug Interaction Instruction
Avoid milk and antacid
FOLATE ( FOLIC ACID ) 1 MG orally DAILY
GLIPIZIDE 2.5 MG orally DAILY
LISINOPRIL 5 MG orally DAILY
MILK OF MAGNESIA ( MAGNESIUM HYDROXIDE )
30 MILLILITERS orally DAILY as needed Constipation
LOPRESSOR ( METOPROLOL TARTRATE ) 12.5 MG orally every 8 hours
HOLD IF: heart rate<55 , sbp<100 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
OMEPRAZOLE 40 MG orally DAILY
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
1 TAB orally DAILY
Alert overridden: Override added on 7/9/07 by
SOSAYA , AMBERLY , M.D. , PH.D.
POTENTIALLY SERIOUS INTERACTION: ATORVASTATIN CALCIUM &
NIACIN , VIT. B-3 Reason for override: mda
DIET: No Restrictions
ACTIVITY: Resume regular exercise
FOLLOW UP APPOINTMENT( S ):
Appointment with your primary care physician , Dr. Scheffer at P Therford Hospital 7/25/07 Wed 2:45pm ,
ALLERGY: Penicillins
ADMIT DIAGNOSIS:
Chest pain , weakness
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
same
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD history of CABG x 2 ( coronary artery disease ) RAS c L renal stent
bilateral common iliac artery stents
PAF ( paroxysmal atrial fibrillation ) R CEA DM ( diabetes mellitus )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
Trans-thoracic echo
Serial cardiac enzymes and labs
Carotid ultrsound
BRIEF RESUME OF HOSPITAL COURSE:
CC: Severe weakness , chest pain in the ED.
HPI: 82 F with history of HTN , DM , CAD history of CABG x 2 ( stents x 4 ). In RHMC ,
but progressively feeling worse , until acutely weak this a.m.. Could
not get out of bed. Daughter was around and she called EMS
at patient's request. Recv'd asa 325mg x 1 in the ambulance. Denies
CP/SOB/N/V/melanotic stools/BRBPR/cough/fevers/chills/dysuria in the
last few days. Does note decreased apetite , and mostly consuming
liquids in the last two days. Does report taking lactulose x 2 2/2
constipation x 2-3 days Had pacer placement about a month ago.
In ED: SBP 190's , developed CP about 1h after admission. given nitro
and morphine 3mg repeat blood pressure 98/50s , rebounded to 160s/50s prior to
transfer to floor. Chest pain resolved. ? T wave changes in the
inferior leads from previous.
***
PMH: 1. HTN2. DM
3. CAD CABG x 2 ( re-do sternotomy both in the 70's and the 90's ) PCI
x 2 ( 4 stents ) Pacer placement
'2007 4. Left Renal artery stenosis history of
stent 5. Paroxysmal atrial
fibrillation 6. Right carotid
endarterectomy. 7. Bilateral iliac stents
***HOME MEDS:
1. ASA 325 daily 2. plavix 75 daily 3. glipizide 2.5 daily 4. toprol
XL 100 daily , 5. lisinopril 10 every day 6. lipitor 80
daily 7. colace 100mg twice a day 8. omeprazole 40
every day 9. Lactulose every day before noon/every afternoon as needed
constipation 10. senna twice a day as needed
constipation 11. celexa --> patient denies
taking ALLERGIES: PCN
( rash ) FH:
noncontributory SH: lives with son ( Kaemmerling ) ,
4 children A&W in area , retired RN from Put Wathern Hospital
Una Cousins tel No's: 314-416-9306 cell
354-244-8635 Alleen Deck tel: 144-340-9527 and
work 081-927-1533 ext 6613 remote ( 20 yrs ago ) tobacco hx , denies
ETOH and illicit drug use
***
PE on ADMISSION: VS: Afeb HR 59 , BP 165/51 , RR 20 , SaO2 100% 2
L Gen: elderly female lying supine , appearing very
weak and mildly somnolent NAD , oriented to
place/person/time HEENT: NCAT , anicteric sclera , mmm , upper
dentitions CHEST:
CTAB CV: RRR S1S2 , SEM I-II /
VI ABD: many old healed surgical scars , no rashes ,
+BS , soft , NTND , no HSM , no RT/G EXT: wwp , no e/c/c , 2+ DP's. Well
healed surgical scars
SKIN: intact , no rashes NEURO: CN II-XII intact , no focal deficits;
A+O x 3
***
RESULTS: nasal 134 K 4.0 CL 99 CO2 27 BUN 17 CRE 1.1 GLU
110 CA 8.6 PHOS 3.1 MG 2.2 TBILI 0.5 TP 6.2 ALB
3.5 GLOB 2.7 ALT/SGPT 11 , AST/SGOT 18 , ALKP 90 , TBILI
0.5 3:30PM Set: CK 27 , CK-MB 1.5 TROP-I <0.04
WBC 6.18 HCT 27.5 PLT 327 physical therapy 14.8 PTT 33.7
INR-1.2 Urinalysis- entirely
negative
***
Studies/Imaging: Portable CXR:
Neg EKG: Normal sinus , paced @ 61 bpm , TWI in V5 , V6 ,
I , II , AVF ( likely old when c/with prior EKG ) , No acute ST changes
noted
*****
A/P: 83y F with MMP and increasing weakness , new onset of chest pain.
ROMI.
CV- HDS currently.
- Cardiac telemetry and pulse ox continuous
- ASA 325mg every day - Plavix 75mg every day - Atorvastatin 80 mg every day
- Lopressor 12.5mg orally every 8 hours - Lisinopril 5mg orally every day
- ROMI- done- no evidence of MI.
------
Hct 27.5 on presentation. Hx of CAD.
- 1u pRBCs with lasix 20u x 1 intravenous to chase
----
TTE -EF 50% no wall motion abnl. unchanged
----
Neuro- Chest pain has resolved. No current pain issues. No acute
neuro changes. Hx of depression. Morphine 1-2mg intravenous as needed pain , did not
require since day 1.
Consulted psychiatry- recommended celexa 30mg orally every day
Consulted Neurology- Some autonomic instability ( hypotension ) with
standing. Recommended JOBST stockings , and if still problematic
consider low dose mineralocorticoid treatment ( somewhat of a problem
when considering her other comorbidities ).
-----------
***Carotid U/S done - interval worseninig of R mid int lesion to - 55%
*** Will need followup
---------
Resp- Hx of smoking. No current respiratory issues.
Will CTM closely along with fluid status GI-
Constipation cont colace/senna/mom/malox
cont prilosec
Endo- SSI medium scale while in house
TSH 5-8 in house. TFTs done -wnl t3-72 , t4-8. No benefit to thyroid
supplementation , especially given comorbidities ( risk of sinus tach ,
osteoporosis , etc ).
ID- no issues. check UA
Heme- Hct 27.5. 1upRBCs as noted above. Retic's -3.7% appropriate. Some
iron-deficiency anemia. Supplemented with Iron , multivitamin , folate , one
b12 shot.
Psych- will restart celexa. psych consult
obtained.
PPx's : lovenox 40mg subcutaneously while in-house.
Dispo: to rehab
FULL CODE
ADDITIONAL COMMENTS: ** Please use TEDS thigh-high.
** Please call your primary care physician , Dr. Scheffer with questions
** Please obtain Jobst stockings through your primary care physician's office when
available.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Please followup with further workup of anemia. Component of iron
deficiency anemia on presentation here. Probably anemia of chronic
disease. ?Role for procrit
2. Carotid ultrasound with 50-55% lesion , asymptomatic. Should follow
No dictated summary
ENTERED BY: SOSAYA , AMBERLY , M.D. , PH.D. ( TX586 ) 1/27/07 @ 03:56 PM
****** END OF DISCHARGE ORDERS ******

Document id: 49

032003429 | PUO | 50415670 | | 9990182 | 7/24/2006 12:00:00 a.m. | Coronary artery disease 414.01 | | DIS | Admission Date: 6/5/2006 Report Status:

Discharge Date: 10/23/2006
****** FINAL DISCHARGE ORDERS ******
BEEBEE , MINNIE 809-39-21-7
Pla Las Hisdence
Service: CAR
DISCHARGE PATIENT ON: 10/19/06 AT 02:00 PM
CONTINGENT UPON Attending evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: KUSH , QUINN J. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ENTERIC COATED ASA 325 MG orally DAILY
TESSALON PERLES ( BENZONATATE ) 100 MG orally three times a day
as needed Shortness of Breath
Number of Doses Required ( approximate ): 6
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
Starting IN a.m. ( 8/2 )
CODEINE PHOSPHATE 15 MG orally every 3 hours as needed Pain
HOLD IF: sedated , rr<12
DEXTROMETHORPHAN HBR 10 MG orally every 6 hours as needed Other:cough
HOLD IF: sedated , rr<12
Number of Doses Required ( approximate ): 6
ZETIA ( EZETIMIBE ) 10 MG orally DAILY
LANTUS ( INSULIN GLARGINE ) 20 UNITS subcutaneously BEDTIME
HOLD IF: call HO if BG <90
POTASSIUM CHLORIDE IMMED. REL. ( KCL IMMEDIATE... )
*** LOW KCL REPLACEMENT SCALE ORAL orally Scale Frequency
1. Only KCL Immediate Release products may be used for KCL
scales.
2. Do not use sustained-release potassium for KCL scale
doses. 3. Replace KCL based on lab values.
4. As per PUO Potassium Chloride Policy: each 20 mEq dose
is to be given with 4oz of fluid.
5.A serum creatinine must be ordered and checked daily
while patient is ordered for a K-scale.
6.K-scale cannot be used on patients with:
* A serum creatinine greater than or equal to 2.0 mg/dl; or
* A serum creatinine increase of 0.5 mg/dl within 24
hours.
* Hold scale and contact MD if SCr is greater than 2.0.
-----------------------------------------------------------
----------- If K+ Level is less than 3.1 then call H.O.
If K+ Level is 3.1-3.3 , then administer KCL 40 meq orally
followed by 20
meq orally 2 hours later. Recheck K+ Level 2 hours after
dose was given.
If K+ Level is 3.4-3.6 , then administer KCL 40 meq orally
Recheck K+ Level 2 hours after dose was given.
If K+ Level is 3.7-4.0 , then administer KCL 20 meq orally
Recheck K+ Level 2 hours after dose was given.
If K+ Level is 4.1-5.0 , then DO NOT administer KCL.
Recheck K+ Level in every day before noon
If K+ Level is greater than 5.0 then call H.O.
-----------------------------------------------------------
-----------
Override Notice: Override added on 10/19/06 by
BALDAUF , WILLOW N. , M.D.
on order for DIOVAN orally ( ref # 269432644 )
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
VALSARTAN Reason for override: aware
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
MAGNESIUM GLUCONATE Sliding Scale orally ( orally ) DAILY
-> Mg-scales cannot be used and magnesium doses must be
individualized for patients who have:
- a serum creatinine greater than or equal to 2.0 mg/dL; or
- a serum creatinine greater than or equal to 1.5 mg/dL
and an increase of 0.5mg/dL within 24 hours.
Call HO if Mg level is less than 0.8
If Mg level is less than 1 , then give 3 gm Mg Gluconate
orally and call HO
If Mg level is 1.0-1.5 , then give 2 gm Mg Gluconate orally
If Mg level is 1.6-1.9 , then give 1 gm Mg Gluconate orally
If Mg level is 2.0-2.5 , then Do Not administer Mg
Gluconate Call HO if Mg level is greater than 2.5
NITROGLYCERIN 1/150 ( 0.4 MG ) 1 TAB sublingual q5min x 3
as needed chest pain HOLD IF: SBP < 100
OXYCODONE 5-10 MG orally every 6 hours as needed Pain
PINDOLOL 5 MG orally twice a day HOLD IF: sbp<90 , HR<50
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
ZOCOR ( SIMVASTATIN ) 80 MG orally BEDTIME
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
DIOVAN ( VALSARTAN ) 160 MG orally DAILY
Starting IN a.m. ( 1/20 )
Alert overridden: Override added on 10/19/06 by
BALDAUF , WILLOW N. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
VALSARTAN Reason for override: aware
Number of Doses Required ( approximate ): 5
DIET: House / Low chol/low sat. fat
DIET: House / ADA 2100 cals/dy
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
Lift restrictions: Do not lift greater then 15 pounds
FOLLOW UP APPOINTMENT( S ):
Dr. Kush He will arrange. ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Elective cardiac catheterization with PCI
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Coronary artery disease 414.01
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD
OPERATIONS AND PROCEDURES:
Cardiac catheterization with stent to old CABG vessel
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
CXR
BRIEF RESUME OF HOSPITAL COURSE:
CC: Elective Cardiac Cath
HPI: 58 year-old female smoker with hx of CAD , history of CABG x3 , DM II , HTN , and
hyperlipidemia admitted to the CCU after elective cardiac cath history of
abnormal stress test. Cath showed impaired flow in the inferior
and posterolateral zones due to obstructive degenerative disease in
the SVGs to the RCA and LCF-OM. Stent placed in the RCA graft though
there was extensive calcification and difficulty
obtaining full stent expansion , and following the stent deployment
there was poor reflow accompanied by mild chest pain and EKG changes ,
without hemodynamic embarrassment. patient was transferred back
to the CCU stable and without pain. patient was scheduled for call out to
floor , but had an episode of jaw sensation , different from previous
angina. patient was upset by turn of events , but was calmed by staff. Was
then evaluated by Dr. Kush and came out to the floor Na night.
PMH
DMII , HTN , Hyperlipidemia , Cirrhosis history of CABG x 3
1997 history of AAA repair
1996 history of aorto-fem bypass
1996 history of
TAHBSO Meds
Lantus 40u every day Estradiol 0.05
Diltiazem 180 mg every day HCTZ 25 mg
every day Zetia 10mg
every day Diovan 160 mg
every day Plavix 75 mg
every day Zocor 80 mg
every day ASA 325 mg
every day MV
Meds in CCU ASA 325 mg every day
Lantus 20u every day Plavix 75 mg
every day Zetia 10mg
every day Famotidine 20 mg
twice a day Pindolol 5 mg
twice a day Lovenox 40 subcutaneously
every day nicotine
patch MgSO4
SS KCL SS
Novolog SS patient
Status Vitals
Gen - Awake , Alert , NAD HEENT - JVP 6 cm , No
bruits Chest - CTAB with mild rhonchi/wheezes
R>L CV - RRR , Nml S1 , S2 , II/VI SEM at
LLSB Abd - Soft , NT , ND , No
organomegaly Extr - L femoral bruit , R cath site , oozing , no
edema , hematoma , ecchymosis present
Studies CAth -
Right Dominant Circulation
Left Main Coronary Artery
No significant LM lesions identified
Left Anterior Descending Artery
LAD ( Proximal ) , Discrete 90% lesion
LAD ( Ostial ) , Discrete 90% lesion
Left Circumflex Artery
CX ( Proximal ) , Discrete 90% lesion
Right Coronary Artery
RCA ( Proximal ) , Discrete 100% lesion
RT PDA ( Mid ) , Discrete 100% lesion
Coronary Artery Bypass Grafts:
SVG Graft to RT PDA ( Mid ) , Discrete 90% lesion STENT to 20%
LIMA Graft to LAD
SVG Graft to MARG1 ( Ostial ) , Discrete 90% lesion
SVG Graft to MARG1 ( Proximal ) , Discrete 90% lesion
Collateral flow from LAD to RT PDA
A/P
1. Cardiac Ischemia- patient had elective PCI on 9/6/06 with results as
mentioned previously. She did experience jaw sensations and chest pain
post procedure that she describes as different from periprocedure pain ,
and previous episodes of angina. After release from CCU , had no further
events. No current chest or jaw pain. Continuing plavix , zocor , zetia
as outpt and heparin and Integrelin have been discontinued.
Pump- physical therapy has preserved fxn , BP low normal , patient euvolemic.
Rhythm - NSR on telemetry will d/c on Betablocker.
2. Pulm - patient has chronic cough due to Post nasal drip. Taken off of her
antihistamine on admission. It is USOH per patient DID NOT GIVE
ANTIHISTAMINES in this hospital course. CXR was normal with no acute
changes on admission.
3. Renal - NO hx of renal dz , No renal issues during hospital course.
4. Endo - DMII on Lantus , Novolog SS , while in the hospital.
FS Glu monitored. No adjustment needed. Will send out on home doses o
insulin.
5. Heme - patient had cath and subsequent oozing from site in groin. Hct was
stable post cath , Anticoagulation stopped. patient to be discharged on home
meds including plavix and ASA.
ADDITIONAL COMMENTS: Please return if you have any chest pain , jaw pain , shortness of breath ,
groin pain , groin swelling , dizziness , or fever and chills. Please take
medicines as previously prescribed. Please limit activity for the next
few day to non-strenuous work. Please make follow up appts. with primary
care physician and cardiologist within the next 2 weeks.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
Please follow up on groin site and evaluate for bruits or hematoma.
Please follow Hct to ensure no acute blood loss.
No dictated summary
ENTERED BY: KUSH , QUINN J. , M.D. ( PQ5 ) 10/19/06 @ 05:01 PM
REVIEWED BY: KUSH , QUINN J. , M.D.
****** END OF DISCHARGE ORDERS ******

Document id: 50

488940606 | PUO | 19781692 | | 951619 | 8/27/1991 12:00:00 a.m. | Discharge Summary | Signed | DIS | Admission Date: 10/8/1991 Report Status: Signed

Discharge Date: 10/17/1991
PRINCIPAL DIAGNOSIS: PERIPHERAL VASCULAR DISEASE.
HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old male
who presented to the Emergency Room
complaining of blue right toes. The patient has no known vascular
disease. Over the past two years , the patient has developed
progressive claudication. He currently is able to walk about one
block before having to stop. He was otherwise well until about one
and a half weeks prior to admission when , for two days after
cutting his toenails , he noted increasing pain and blue coloring of
his right fifth toe. He thought that he injured the toe when
cutting the nail. He cut the skin on the plantar side of the right
third toe accidently five days prior to admission. He then
presented with blue coloration of the third , fourth and fifth toes
and intense pain over the fifth toe. He has no history of erythema
extending up his foot or leg. He has no history of diabetes. No
fever or chills. No history of atrial arrhythmias. No heart
disease , syncopal episodes. No low back or buttock pain. No
erectile dysfunction. He has no history of an abdominal aortic
aneurysm. He is a smoker with two packs for 20 years. No history
of hypertension or hypercholesterolemia. He had no history of TIA ,
CVA , myocardial infarction or angina. PAST MEDICAL HISTORY:
Varicose veins. MEDICATIONS: None. ALLERGIES: NO KNOWN DRUG
ALLERGIES.
PHYSICAL EXAMINATION: On admission revealed the patient to be
afebrile and stable. Head exam was normal.
Neck exam was supple with full range of motion. Lungs were clear
bilaterally. Heart revealed a regular rate and rhythm , normal S1
and S2 , no CVA tenderness. Abdomen was obese , soft , no palpable
masses , normal bowel sounds. Groin showed no hernias. Pulses were
significant for 1+ dopplerable femorals bilaterally , 2+
dopplerable dorsalis pedis bilaterally , 1+ dopplerable posterior
tibial on the right , 2+ dopplerable posterior tibial on the left
and 2+ dopplerable popliteals. Rectal exam was guaiac positive
with some pain and no visible lesions. ABI was .66 of the dorsalis
pedis on the right , .44 of the dorsalis pedis on the left; .61
posterior tibial on the right and .66 posterior tibial on the left.
HOSPITAL COURSE: The patient was admitted for intravenous
heparinization. He underwent an angiogram which
showed 90% stenosis of the iliac bifurcation on the right , greater
than 50% narrowing of the distal common iliac and diffuse narrowing
throughout the vessel. His SFA and popliteals were patent on the
right. On the left he had occlusion of the left common iliac with
reconstruction of the common femoral. His SFA was occluded
proximally with reconstitution at the adductor canal and one vessel
peroneal run off. His post angio creatinine was 1.1. Cardiology
was consulted and their impression was that he had severe bilateral
peripheral vascular disease with a question of an embolic event to
the right toe. They recommended that if surgery became necessary
that he had perioperative Nitropaste and check postoperative EKG's
and enzymes. He was sent home for follow-up in the clinic.
DISPOSITION: MEDICATIONS: On discharge included Vasotec , 5 mg
orally every day; aspirin , one tablet per day; Nicorette gum
for smoking cessation.
IO582/2817
BUCK MOOSE , M.D. PZ17 D: 11/13/91
Batch: 3692 Report: Q0467J47 T: 2/3/91
Dictated By: DESIRAE MARCOTT , M.D.

Document id: 51

010746671 | PUO | 42234794 | | 745127 | 2/20/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 10/9/1990 Report Status: Unsigned

Discharge Date: 6/26/1990
HISTORY OF PRESENT ILLNESS: This is a 37 year old female who has
had pain in her old appendectomy
incision. The patient has had pain intermittently in the right
lower quadrant in the old appendectomy scar for many years. She
denies nausea or vomiting , or history of intestinal obstruction.
PAST MEDICAL HISTORY: Is significant for hypertension. She had an
appendectomy in 1965. She had a right carpal tunnel release in
1985 , and a right wrist tendon surgery in 1987. She has chronic
obstructive pulmonary disease. MEDICATIONS ON ADMISSION:
Hydrochlorothiazide 25 q-day and Seldane as needed for allergies.
ALLERGIES: PENICILLIN CAUSES A RASH , MORPHINE CAUSES NAUSEA AND
VOMITING. She does not smoke and only occasionally drinks. REVIEW
OF SYSTEMS: Is noncontributory.
PHYSICAL EXAMINATION: Blood pressure is 130/90 , heart rate is 80.
In general , this is an overweight , otherwise
well female. The lungs were clear to auscultation. Heart was a
regular rate and rhythm , with no murmurs , rubs , or gallops. Pulses
were 2+ in the radial and dorsalis pedis. Abdomen: Soft , obese ,
nontender , with some mild incisional tenderness over the area of
the appendectomy scar. Neurological examination was nonfocal.
ASSESSMENT: Was a 37 year old female with pain in the old
appendectomy scar. The plan was for an incisional hernia repair
and exploration.
HOSPITAL COURSE: The patient was taken to the operating room on
8/6/90 .  The procedure performed was an
incisional hernia repair by Dr. Throneburg and Dr. Bulls . The patient
tolerated the procedure well and was returned to the floor that
evening. Since that time , the patient has had been somewhat slow
to mobilize. She has complained of some nausea and some pain in
the abdomen. She was given a PCA pump for the pain. The patient
on 10/28/90 developed marked pain and much difficulty ambulating.
Minimal orally intake was thought to be going on at this time. On
10/15/90 , the patient began to be doing much better. She had slow
ambulating despite the PCA pump , but was felt by Dr. Throneburg that the
patient would continue to improve , and we could increase the orally
medications and switch to a plan for discharge tomorrow.
DISPOSITION: She was discharged on the following medications:
Percocet one to two orally q4-6 hours ,
Hydrochlorothiazide 20 mg orally q-day were the extent of her
medications. FOLLOWUP: She is to be followed in the office by Dr.
Throneburg as an outpatient.
________________________________ YK127/4929
FLORETTA THRONEBURG , M.D. , PH.D. OX92 D: 6/16/90
Batch: 2769 Report: J0154F41 T: 2/25/90
Dictated By: ELENA S. BIALY , M.D. FO02
cc: ANDNOCK STOWNCHILD MEDICAL CENTER

Document id: 52

598555919 | PUO | 29607759 | | 0366252 | 6/11/2006 12:00:00 a.m. | Chest pain | | DIS | Admission Date: 10/22/2006 Report Status:

Discharge Date: 10/1/2006
****** FINAL DISCHARGE ORDERS ******
PEELMAN , THEODORE 315-81-02-4
Flint En Kanprai
Service: CAR
DISCHARGE PATIENT ON: 2/13/06 AT 03:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: BURVINE , ALVERTA A. , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
NORVASC ( AMLODIPINE ) 5 MG orally DAILY HOLD IF: sbp<90
Food/Drug Interaction Instruction
Avoid grapefruit unless MD instructs otherwise.
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
PLAVIX ( CLOPIDOGREL ) 75 MG orally DAILY
Starting IN a.m. ( 7/26 )
ECASA 325 MG orally DAILY
ID-RANOLAZINE 1 , 000 MG orally twice a day Starting Today ( 7/26 )
Instructions: AH Study drug- patient has pills at bedside.
Should take
2 pills twice a day ( 1000mg twice a day ) as part of study protocol.
Could be placebo.
IMDUR ER ( ISOSORBIDE MONONITRATE ( SR ) ) 90 MG orally twice a day
Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
LISINOPRIL 5 MG orally DAILY HOLD IF: sbp<90
Alert overridden: Override added on 5/1/06 by
FRIES , SPENCER L. , M.D.
POTENTIALLY SERIOUS INTERACTION: POTASSIUM CHLORIDE &
LISINOPRIL Reason for override: will monitor
LOPRESSOR ( METOPROLOL TARTRATE ) 50 MG orally every 6 hours
HOLD IF: SBP<90 , HR<55 Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
DENAVIR CREAM ( PENCICLOVIR ) CREAM TP every 2 hours W/A X4DAYS
Number of Doses Required ( approximate ): 10
DIET: House / Low chol/low sat. fat
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
primary care physician Dr Jackson Part , Fencop Sepull Vierf Rd 8/28/06 at 2:45 pm ,
Dr. Burvine Within 6 weeks ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
chest pain
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Chest pain
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
CAD history of 1vCABG '76 , 3vCABG '94 history of rad
prostatectomy history of prostate CA urethrocolonic fistula history of pilonidal cyst
OPERATIONS AND PROCEDURES:
Cardiac cath , L heart
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
None
BRIEF RESUME OF HOSPITAL COURSE:
**CC: chest pain
**HPI: 74 year-old man , vasculopath , with history of CABG x 2 ( 1976 & 1994 ) , presents
with history of sudden onset of substernal chest pain which came and went
starting 2 days PTA. Was exerting self when felt onset of dull
pressure like pain a/b slight sob and squeezing sensation -
typical angina. Instead of declining , continued and was constant for
the next 24-30 hours , waxing & waning. Took over 25 sublingual nitro in that
time period. Presented to OMC on day of admission with TNI
elevation , no longer in pain , lateral ST depressions ( subtle ). Had
SOB on night prior to admit; no PND/orthopnea. Pain never a/b
nausea/vom/diaphoresis.
********
**PMHx: CABG x 2: ?DM , hyperlipidemia , radical
prostatectomy **Meds: toprol 200 every day , isosorbide 180 every day , norvasc 5
every day , lipitor 80 every day , asa 325 every day , ibuprofen as needed **ALL:
NKDA **Admit PE: 99.7 100 124/60 20 95% 2L , NAD , mmm , JVP
@ear , bibasilar crackles , RRR , 2/6 SM. NABS , soft , nt , nd. NO PULSE
RLE DP. +2 DP/physical therapy LLE. Neuro: A&Ox3.
********
**Labs: HCT 36 , Cr 0.7 , TNT 0.24 , Ck 214 , MB 21.6 **EKG: ST 100 , St
dep'rn 0.5 mm V4-V6. **CXR: pulm
edema
********
NB: on yyTC trial. if patient having weird ss , eg nausea , stomach
upset , or if he is having severe chest pain , would call the AH team
sooner rather than later. if questions , would call Verna Jonte
( team's cards fellow @ 46735 ) or Dr. Versie Pasaya 27215 )
********
DAILY STATUS: BP 100s , no chest pain , NAD. A&O x 3. JVP at 10 cm.
otherwise unchanged from admission. A/P: 74 year-old M with CABG x 2 p/with chest
pain , NSTEMI likely happened several days prior to admit.
**CV: ( i ) - NSTEMI. L heart cath revealed patent CABG grafts , no
intervenable disease. Decision to medically manage on
GPIIb/IIIa inhib/heparin in house only and ECASA/Plavix/BB/Lipitor/ACE
inhib/nitrates now and at home. Also enrolled in AH study on
ranolazine vs placebo. Troponin trended down. Pain free at time of
discharge. ( r ) on
tele ( p ) chf on exam. post-NSTEMi echo chowed LV EF 40% , mild-mod
dilation. AK ant/inf septum and basal post segment. diuresed , cont lasix
at home , will need lytes checked. **HEME: anemia - iron
studies unrevealing given NL ferritin. Hct stable in house , follow as
outpatient**ENDO: history of ?DM. hgb a1c nl , lipids appropriate. cont
lipitor. Did have elevated figner sticks in house , re-scren for DM as
outpaient. **GU: history of radical prostatectomy which left him with a
recto-ureteral fistula and he often has stool-laden urine. chooses
not to have this repaired at present. **PPX: was on
heparin , ambulate at home **FULL
CODE
ADDITIONAL COMMENTS: Take your new medicines as directed. You will need your electrolytes
checked in the next 1-2 weeks given the new meds , so please see your primary care physician
around 1 week from now for evaluation. If you feel chest pain that is
worsening , shortness of breath , sweating , or other concerning symptoms ,
please call your doctor or call 911.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
primary care physician in 7 days. Check lytes at that time ( starting lasix and ACE inhib ).
Check BP as well.
No dictated summary
ENTERED BY: SHUGRUE , MOSHE , M.D. ( ZB13 ) 2/13/06 @ 03:58 PM
****** END OF DISCHARGE ORDERS ******

Document id: 53

415842495 | PUO | 78560075 | | 3419127 | 4/4/2006 12:00:00 a.m. | bacteremia | | DIS | Admission Date: 9/19/2006 Report Status:

Discharge Date: 10/20/2006
****** FINAL DISCHARGE ORDERS ******
DEARTH , DEIRDRE T. 104-60-01-0
Ta
Service: ONC
DISCHARGE PATIENT ON: 11/8/06 AT 11:00 a.m.
CONTINGENT UPON SNF/rehab
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: DOEPKE , MELVIN N. , M.D.
CODE STATUS:
Full code
DISPOSITION: Skilled Nursing Facility
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 6 hours
as needed Pain , Temperature greater than:101 , Other:transfusion
premedication
ALBUTEROL NEBULIZER 2.5 MG inhaled every 4 hours as needed Wheezing
TESSALON PERLES ( BENZONATATE ) 100 MG orally three times a day
as needed Other:congestion
CALTRATE 600 + D ( CALCIUM CARBONATE 1 , 500 MG ( ... )
2 TAB orally twice a day
PERIDEX MOUTHWASH ( CHLORHEXIDINE MOUTHWASH 0.12% )
15 MILLILITERS MO twice a day
Instructions: pls use this or nystatin s+s
BENADRYL ( DIPHENHYDRAMINE ) 12.5 MG orally x1
as needed Other:pre-transfusion
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day as needed Constipation
ENOXAPARIN 40 MG subcutaneously DAILY
NEXIUM ( ESOMEPRAZOLE ) 40 MG orally DAILY
FLOVENT HFA ( FLUTICASONE PROPIONATE ) 110 MCG inhaled twice a day
INSULIN ASPART Sliding Scale ( subcutaneously ) subcutaneously before meals
Starting Today ( 4/9 )
If BS is less than 125 , then give 0 units subcutaneously
If BS is 125-150 , then give 2 units subcutaneously
If BS is 151-200 , then give 3 units subcutaneously
If BS is 201-250 , then give 4 units subcutaneously
If BS is 251-300 , then give 6 units subcutaneously
If BS is 301-350 , then give 8 units subcutaneously
If BS is 351-400 , then give 10 units subcutaneously and
call HO Call HO if BS is greater than 400
INSULIN NPH HUMAN 10 UNITS subcutaneously every day before noon
ATROVENT NEBULIZER ( IPRATROPIUM NEBULIZER )
0.5 MG inhaled four times a day
POTASSIUM CHLORIDE IMMED. REL. ( KCL IMMEDIATE... )
***LOW KCL IMMEDIATE RELEASE REPLACEMENT SCALE ORAL orally
Scale Frequency
1. Only KCL Immediate Release products may be used for KCL
scales.
2. Do not use sustained-release potassium for KCL scale
doses. 3. Replace KCL based on lab values.
4. As per PUO Potassium Chloride Policy: each 20 mEq dose
is to be given with 4 oz of fluid.
5. A serum creatinine must be ordered and checked daily
while patient is ordered for a K-scale.
6. K-scale cannot be used on patients with:
* A serum creatinine greater than or equal to 2.0 mg/dl; or
* A serum creatinine increase of 0.5 mg/dl within 24 hours.
* Hold scale and contact MD if SCr greater than 2.0.
-----------------------------------------------------------
----------- If K+ Level is less than 3.1 then call H.O.
If K+ Level is 3.1-3.3 , then administer KCL 40 meq orally
followed by 20
meq orally 2 hours later. Recheck K+ Level 2 hours after
dose was given.
If K+ Level is 3.4-3.6 , then administer KCL 40 meq orally
Recheck K+ Level 2 hours after dose was given.
If K+ Level is 3.7-4.0 , then administer KCL 20 meq orally
Recheck K+ Level 2 hours after dose was given.
If K+ Level is 4.1-5.0 , then DO NOT administer KCL.
Recheck K+ Level in every day before noon
If K+ Level is greater than 5.0 then call H.O.
-----------------------------------------------------------
-----------
POTASSIUM CHLORIDE SLOW REL. ( KCL SLOW RELEASE )
40 MEQ orally DAILY As per PUO Potassium Chloride Policy:
each 20 mEq dose to be given with 4 oz of fluid
LACTULOSE 30 MILLILITERS orally DAILY as needed Constipation
ATIVAN ( LORAZEPAM ) 0.5-1 MG intravenous every 8 hours as needed Nausea
HOLD IF: sedate or rr<10
MAALOX-TABLETS QUICK DISSOLVE/CHEWABLE 1-2 TAB orally every 6 hours
as needed Upset Stomach
MAGNESIUM GLUCONATE Sliding Scale orally ( orally ) DAILY
-> Mg-scales cannot be used and magnesium doses must be
individualized for patients who have:
- a serum creatinine greater than or equal to 2.0 mg/dL; or
- a serum creatinine greater than or equal to 1.5 mg/dL
and an increase of 0.5mg/dL within 24 hours.
Call HO if Mg level is less than 0.8
If Mg level is less than 1 , then give 3 gm Mg Gluconate
orally and call HO
If Mg level is 1.0-1.5 , then give 2 gm Mg Gluconate orally
If Mg level is 1.6-1.9 , then give 1 gm Mg Gluconate orally
If Mg level is 2.0-2.5 , then Do Not administer Mg
Gluconate Call HO if Mg level is greater than 2.5
MAGNESIUM SULFATE Sliding Scale intravenous ( intravenously ) DAILY
-----------------------------------------------------------
------ Physician Instructions:
Magnesium scales cannot be used on patients with:
-> A serum creatinine greater than or equal to 2.0 mg/dL;
or
-> A serum creatinine increase of 0.5 mg/dL within 24
hours.
-----------------------------------------------------------
-------- Call HO if Mg level is less than 1.2
Hold order if creatinine is greater than 1.9
If serum Mg level is less than 1.4 , then give 5 gm Mg
Sulfate intravenously and call HO
If serum Mg level is less than 1.6 , then give 4 gm Mg
sulfate intravenously
If serum Mg level is less than 1.8 , then give 3 gm Mg
Sulfate intravenously
If serum Mg level is less than 2.0 , then give 2 gm Mg
Sulfate intravenously
Call HO if Mg level is greater than 2.5
MS CONTIN ( MORPHINE CONTROLLED RELEASE ) 15 MG orally twice a day
Starting Today ( 4/9 ) HOLD IF: rr<10 or very sleepy
NYSTATIN SUSPENSION 10 MILLILITERS orally four times a day
Instructions: use this or chlorhexidine
ZOFRAN ( POST-OP N/V ) ( ONDANSETRON HCL ( POST-... )
1 MG intravenous every 6 hours X 2 doses as needed Nausea
OXYCODONE 5 MG orally every 6 hours as needed Pain
KCL ( POTASSIUM CHLORIDE )
***MODERATE KCL REPLACEMENT SCALE 10 mEq/HR intravenous Scale
Frequency 1. Replace KCL based on lab values.
2. An infusion pump is required for all intermittent bolus
infusions.
3. KCL 10 mEq/100ml/heart rate is intermittent bolus infusion
standard.
4. A serum creatinine must be ordered and checked daily
while patient is ordered for a K-scale.
5. K-scale cannot be used on patients with:
* A serum creatinine greater than or equal to 2.0 mg/dl; or
* A serum creatinine increase of 0.5 mg/dl within 24 hours.
* Hold scale and contact MD if SCr greater than 2.0.
-----------------------------------------------------------
----------- If K+ Level is less than 3.1 then call H.O.
If K+ Level is 3.1-3.3 , then administer KCL 10 meq x5
Recheck K+ Level 1 to 4 hours after infusion finished.
If K+ Level is 3.4-3.6 , then administer KCL 10 meq x4
Recheck K+ Level 1 to 4 hours after infusion finished.
If K+ Level is 3.7-4.0 , then administer KCL 10 meq x3
Recheck K+ Level 1 to 4 hours after infusion finished.
If K+ Level is 4.1-4.5 , then administer KCL 10 meq x2
Recheck K+ Level 1 to 4 hours after infusion finished.
If K+ Level is 4.6-5.0 , then DO NOT administer KCL.
Recheck K+ Level in every day before noon
If K+ Level is greater than 5.0 then call H.O.
-----------------------------------------------------------
-----------
SENNA TABLETS ( SENNOSIDES ) 2 TAB orally twice a day as needed Constipation
ZOLOFT ( SERTRALINE ) 25 MG orally BEDTIME
Starting Today ( 4/9 )
Override Notice: Override added on 8/3/06 by
THEPBANTHAO , DARCI H. , M.D.
on order for GEODON orally ( ref # 410797777 )
SERIOUS INTERACTION: SERTRALINE HCL & ZIPRASIDONE HCL
Reason for override: md aware
MULTIVITAMIN THERAPEUTIC ( THERAPEUTIC MULTIVI... )
5 MILLILITERS orally DAILY
VANCOMYCIN HCL 1 GM intravenous every 12 hours
Instructions: plan 14 days , started 3/4 , end 11/14
COMPAZINE ( PROCHLORPERAZINE ) 5-10 MG orally every 6 hours as needed Nausea
Alert overridden: Override added on 11/8/06 by :
POTENTIALLY SERIOUS INTERACTION: IPRATROPIUM BROMIDE &
PROCHLORPERAZINE Reason for override: md aware
DIET: No Restrictions
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
pls f/u with primary oncologist as scheduled ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
hypotension
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
bacteremia
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
iddm ( diabetes mellitus ) hypercholesterolemia ( elevated cholesterol )
htn ( hypertension ) asthma ( asthma ) arthritis ( arthritis ) obesity
( obesity ) history of ccy ( history of cholecystectomy ) metastatic breast cancer
( breast cancer ) pulmonary embolism ( pulmonary
embolism ) depression ( depression )
OPERATIONS AND PROCEDURES:
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
na
BRIEF RESUME OF HOSPITAL COURSE:
CC: Tachycardia
HISTORY OF PRESENT ILLNESS: This 59-year-old woman from Eyclear Romin presents with fever and tachycardia
since 7/12/06 .  It is very difficult to elicit a clear story. The
patient has had cough productive of variably colored sputum ( yellow
to green to orange , without hemoptysis ) but it seems she may
have had a similar cough for months. Similarly , she notes dysuria
and increased frequency which it seems has also been present for
weeks to months. She is not short of breath and has no headache ,
chest pain , hemoptysis , abdominal pain , nausea , vomiting , diarrhea ,
numbness , LE swelling , LE pain , rash. She does have some bumps on
her abdominal wall which are painful-it sounds like these are a
direct result of the enoxaprin she had been getting for a PE in
October of this year.
The NVH ER doctor spoke with Kiehne at the nursing home. She said
that the patient had an x-ray two days ago which revealed pneumonia ,
and her referral states that the pneumonia was in the left upper
lobe and left lower lobe; the patient was started on Levaquin 500 mg
orally at that time. In the NVH emergency room , the patient was hydrated
with 3 liters of normal saline and her pulse still remains in the
130s. She was given Levofloxacin 500 mg intravenous. The ER physician was
worried about a pulmonary embolus , did not do a chest CT here
because of her elevated creatinine of 1.9. She was transferred to
the Kernan To Dautedi University Of Of for an MRA to rule out PE. In ER here , IJ central line
placed ( CVP~20 ) and patient given 1L NS. Blood pressure systolic
initially 120s but decreased to 90s ( MAPS>70 ) , and norepinephrine
started. The NE was discontinued promptly given BP improvement
immediately , and continued
SBP>100 PAST MEDICAL HISTORY: Metastatic breast CA-bone
scan which revealed widespread osseous metastasis , and
CNS involvement on head CT , bone marrow bx with invasive disease ,
status post brain radiotherapy 1/2 diabetes , PE 10/06 , tx with
enoxaprin through 4/06 ( discontinued because of doubt over original
dx and significant pain at injection sites ) , hypertension , arthritis ,
depression , bipolar disorder , asthma , high cholesterol , anemia , and
obesity.
ONC HISTORY: patient presented with grade III , ER/PR/HER2-negative in
October 2004. In January 2004 , she underwent right breast lumpectomy
with pathology demonstrating 4.1 cm IDC , no LVI ,
negative sentinel lymph nodes. She underwent partial breast radiation
in January 2004 and deferred on adjuvant therapy. In August 2005 , she
presented with atypical chest wall pain and imaging showed bilateral
pulmonary nodules , thoracic lymphadenopathy , and pleural effusion
consistent with metastatic disease. A bone scan showed wide
spread osseous metastatic disease and head CT demonstrated a CNS
involvement. She was treated with whole brain radiotherapy in October
2006 and with weekly Taxol. She continued through October
2006. Restaging studies showed stable visceral disease but
progression of bony metastatic disease. Therefore on March , 2006 ,
she initiated a second-line Navelbine
therapy. PHYSICAL
EXAMINATION: VITAL SIGNS: Temperature 99.3po , pulse 112 regular ,
BP 120/75 , respirations 18 , sO2=100% on ambient air.
GENERAL APPEARANCE: Laying in bed , coughing paroxysms. No use of
accessory muscles. HEENT: Mucosa dry. No jaundice. +conjunctival
pallor. Pupils reactive bilaterally. NECK: Supple and nontender.
Right IJ in place. HEART: S1 , S2 , tachycardic without murmurs. No
heaves. LUNGS: Crackles in the left lower chest
posteriorly , and diffuse expiratory wheezes. ABDOMEN: Soft and
nontender. Small nodule RUQ subcutaneous , mildly tender to
palpation. BACK: No
CVAT. NEUROLOGIC: A&Ox4 , but somewhat sedate and with
poor attention. Radial and DP pulses are 2+. Sensation and strength
are grossly intact. EXTREMITIES: No calf warmth , erythema , or
tenderness. Mild right heel and Achilles tendon tenderness.
LABORATORY RESULTS AT AH WBC 3.2 , hemoglobin 7.5 MCV=76 , platelets
482 , neutrophils 61% , sodium 141 , potassium 3.2 , chloride 122 , CO2
17 , BUN 20 , creatinine 1.5 , glucose 181. LDH 542 , Ca 6.7 Alb
2.2 Urinalysis: 3+ heme , WBC 25-50 , RBC 15-25 , bacteria 1+ , 2+LE ,
neg nitrites. INR 2.0 PTT 43.3.
LABORATORY RESULTS AT WT WBC 3.5 , hemoglobin 9 , hematocrit 28 ,
platelets 592 , neutrophils 68% , sodium 142 , potassium 3.5 , chloride
111 , CO2 14 , BUN 23 , creatinine 1.9 , glucose 217 , alkaline
phosphatase 261 , AST 26 , ALT 27. Urinalysis: Large heme , WBC 6-10 ,
RBC 0-2 , bacteria trace. Blood cultures: Pending. Urine culture
9/3/06: No growth
Chest x-ray: Revealed questionable left lobe infiltrate with
metastasis. EKG: 120 per minute , sinus
tachycardia. CXR: LLL opacity , LUL opacity. Hilar fullness on
the righT>l , and prominent bronchi ( ?cuffing ) on right. Vertebral
fractures. LLL unchanged from 8/27 , and LUL improved C/with known
metastatic disease.
ASSESSMENT: 59 year-old woman with metastatic breast cancer and a
history of pulmonary embolus presenting with one week of fatigue ,
lethargy , tachycardia and fever. History notable for
productive cough and dysuria , although the chronicity of these issues
is unclear. Now growing 1 bottle from NVH as well as PUO of GPC in
clusters empirically on Vanco , now looks to be coag
neg. Discussed with ID , would like to keep vanco PLAN:
*Tachycardia: Most likely secondary to an infection , either
pulmonary or urinary. With improvement in Cr PE CT was obtained which
was negative. Stable. d/c ASA and statin as no role for long term risk
reduction at this time.
*Cough: Productive cough , yellow to green sputum. Seems to have been
present for months , and it is unclear how much this has changed in
the past week. May be chronic secondary to tumor , or may
represent acute infection. Aspiration plausible given mental status.
The CT did not demonstrate any acute etiology for her symptoms.
*Dysuria: Again , chronicity unclear. UA and urine culture at NVH not
very suggestive of UTI , but UA here with 25 wbc and LE+. Has been on
levofloxacin , so will treat until cultures return with ceftazidime
( d/c 10/20 ). *Bacteremia: coag neg staph x2 , Vanc Sens , plan to
treat via PICC with Vancomycin x14days *Oncology: Discussion with Dr.
Triggs , her primary oncologic fellow , who noted that from my
description the patient does not sound much different from her
baseline state. She is mildly tachycardic at baseline ( although not
to this degree ) , and has chronic productive cough and
dysuria. 5. Renal: ARF , improving with IVF. Likely prerenal
azotemia. 6. Heme: Chronic anemia. Given 1UPRBC in ER.
Unfortuantely , the blood was given before hemolysis or iron studies
sent. Would be indicated , especially in setting of markedly elevated
physical therapy. Should be sent in future. I have called and added
on a peripheral manual blood smear. Last INR similarly elevated ( but
I believe patient was on enoxaprin at that time ). Not on enoxaprin
or warfarin now. May be dues to malnutrition , but
concerning for DIC or liver disease. Administered vitamin
K. 7. Psych: Resumed home zoloft , restart
geodon as needed 8. Goals of care: Discussed with the patient and
Dr. Triggs . The patient expresses that she wants to be intubated or
have defibrillation if needed. Dr. Triggs has discussed this numerous
times with her , and will readdress.
ADDITIONAL COMMENTS:
DISCHARGE CONDITION: Stable
TO DO/PLAN:
f/u with primary oncologist
call oncologist or return to ed with any change in symptoms
No dictated summary
ENTERED BY: THEPBANTHAO , DARCI H. , M.D. ( HT541 ) 11/8/06 @ 11:03 a.m.
****** END OF DISCHARGE ORDERS ******

Document id: 54

550926739 | PUO | 91779890 | | 6838563 | 2/2/2006 12:00:00 a.m. | cellulitis , acute renal failure | | DIS | Admission Date: 4/18/2006 Report Status:

Discharge Date: 5/25/2006
****** FINAL DISCHARGE ORDERS ******
EARLGY , LAI 612-11-25-4
U
Service: MED
DISCHARGE PATIENT ON: 10/1/06 AT 12:00 PM
CONTINGENT UPON Not Applicable
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: HANSBERRY , SHAN ROBERTA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home with services
DISCHARGE MEDICATIONS:
TYLENOL ( ACETAMINOPHEN ) 650 MG orally every 4 hours as needed Headache
ALBUTEROL INHALER 2 PUFF inhaled four times a day as needed Wheezing
BACLOFEN 50 MG orally three times a day
KLONOPIN ( CLONAZEPAM ) 0.5 MG orally BEDTIME
COLACE ( DOCUSATE SODIUM ) 100 MG orally twice a day
FOLATE ( FOLIC ACID ) 1 MG orally DAILY
LABETALOL HCL 800 MG orally three times a day
Food/Drug Interaction Instruction
Take consistently with meals or on empty stomach.
NEURONTIN ( GABAPENTIN ) 600 MG orally three times a day
CALTRATE + D 1 TAB orally DAILY
BECLOMETHASONE DIPROPIONATE 160 MCG inhaled three times a day
Instructions: 2 puff of 80mcg inhaler
LIDODERM 5% PATCH ( LIDOCAINE 5% PATCH ) 2 EA TP DAILY
Instructions: Apply one patch to right upper extremity and
right hand
LOTRIMIN TOPICAL ( CLOTRIMAZOLE 1% TOPICAL )
TOPICAL TP twice a day
Instructions: apply to tinea pedis- between toes
Alert overridden: Override added on 2/6/06 by
OSMERS , TESSA M. , PA
SERIOUS INTERACTION: SIMVASTATIN & CLOTRIMAZOLE
SERIOUS INTERACTION: SIMVASTATIN & CLOTRIMAZOLE
Reason for override: topical
LIPITOR ( ATORVASTATIN ) 20 MG orally DAILY
DICLOXACILLIN 500 MG orally four times a day X 10 Days
Starting Today ( 1/3 ) Food/Drug Interaction Instruction
Give on an empty stomach ( give 1hr before or 2hr after
food )
PROTONIX ( PANTOPRAZOLE ) 40 MG orally DAILY
LISINOPRIL 40 MG orally DAILY
COUMADIN ( WARFARIN SODIUM ) 3 MG orally every afternoon
Starting ROUTINE , 20:00 ( Standard Admin Time )
Instructions: Do NOT take tonight 9/17 your INR will be
checked tomorrow
and the coumadin clinic will advise when to restart.
Food/Drug Interaction Instruction
No high Vitamin-K containing foods
Alert overridden: Override added on 10/1/06 by :
POTENTIALLY SERIOUS INTERACTION: SIMVASTATIN & WARFARIN
Reason for override: aware
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Activity as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Lockman primary care physician 12/10/06 at 2:10pm ,
Dr. Chesbro Pain clinic- as needed ,
Arrange INR to be drawn on 10/26/06 with f/u INR's to be drawn every
2 days. INR's will be followed by LMC coumadin clinic 537-738-6908
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
cellulitis
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
cellulitis , acute renal failure
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
hypertension Cl difficile in stool HTN , DVT RLE 1996 history of IVC filter ,
DVT LLE 6/11/02 .  increased lipids. CRI. OSA , on c-pap. history of hemorrhagic
CVA , L-thalamic , 1996. history of RLE tendon release surgery. chronic renal
disease with proteinuria ( chronic renal dysfunction ) chronic venous
stasis ( venous insufficiency ) otitis externa ( otitis externa ) gout
( gout ) OSA ( chronic obstructive pulmonary disease ) obesity
( obesity ) CVA ( cerebrovascular accident )
OPERATIONS AND PROCEDURES:
none
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
LENIs- negative for DVT
BRIEF RESUME OF HOSPITAL COURSE:
CC: Fever , leg swelling
HPI: 44M history of CVA ( R-sided weakness ) , DVT history of IVC filter , morbid
obesity , OSA p/with 1 day of right leg swelling , fever to 103 , and
erythema. Had admission for cellulitis 10/5 , however states leg was
never this large. Started very abruptly and progressed rapidly. Left leg
not affected. No trauma or source of infection noted. In addition has
been treated for otitis externa. He is chronically wheezy.
****
ED Course: LENI's no proximal clot. intravenous ancef given. Nebs. NS 500cc
bolus for elevated cre 2.9->3.7.
****
MEDS: albuterol , flovent , coumadin , klonopin , folate , labetalol ,
lisinopril , norvasc , neurontin , lipitor , protonix , CA+D , baclofen.
****
SH: Wheelchair bound , has home aide , no tob or ETOH
****
EXAM: T99.4 , BP 105/51 , P72 , 99RA.
4+ RLE edema. Chronic venous stasis with underlying erythema. Healed
ulcer right foot. Fresh abrasion right foot.
****
Studies/LABS: Cr 3.7( 2.1-2.9 ) , WBC 11 , HCT 32 ( 31-36 ) , LENI's no
proximal clot
****
Hosptial Course: 45M admitted with cellulitis , RLE edema , acute on
chronic renal failure , and otitis externa.
1 ) Cellulitis: Treated with intravenous nafcillin and leg elevation. Changed to orally
diclox for d/c for more 10days.
2 ) Renal failure: Most likely prerenal- responded to IVF. Cr on discharge
was 1.9.
3 ) Otitis externa: Vosol HC 4drops four times a day given
4 ) HTN: patient was hypotensive ( 80s/50 ) 2/2 asymptomatic. IVF bolus given
and norvasc , lisinopril d/c'd. Continued labetalol with holding
parameters. BP slightly improved so lisinopril restarted.
5 ) Pulm: CPAP , albuterol , flovent
6. ) PROPH: INR 3.5- holding coumadin and restart when <3. VNA to draw INR
on 7/28 .
7. ) SKIN: Tinea pedis- lotrim lotion started twice a day
8. ) PAIN: patient was seen by Dr. Bossert ( outpt pain doctor ) re: baclofen pump.
It was decided pump should remain in place despite it not working because
patient would need surgery to remove it and he does not want surgery.
BRIEF RESUME OF HOSPITAL COURSE ADDENDUM 2:
CC: Fever , leg swelling
HPI: 44M history of CVA ( R-sided weakness ) , DVT history of IVC filter , morbid
obesity , OSA p/with 1 day of right leg swelling , fever to 103 , and
erythema. Had admission for cellulitis 10/5 , however states leg was
never this large. Started very abruptly and progressed rapidly. Left leg
not affected. No trauma or source of infection noted. In addition has
been treated for otitis externa. He is chronically wheezy.
****
ED Course: LENI's no proximal clot. intravenous ancef given. Nebs. NS 500cc
bolus for elevated cre 2.9->3.7.
****
MEDS: albuterol , flovent , coumadin , klonopin , folate , labetalol ,
lisinopril , norvasc , neurontin , lipitor , protonix , CA+D , baclofen.
****
SH: Wheelchair bound , has home aide , no tob or ETOH
****
EXAM: T99.4 , BP 105/51 , P72 , 99RA.
4+ RLE edema. Chronic venous stasis with underlying erythema. Healed
ulcer right foot. Fresh abrasion right foot.
****
Studies/LABS: Cr 3.7( 2.1-2.9 ) , WBC 11 , HCT 32 ( 31-36 ) , LENI's no
proximal clot
****
Hosptial Course: 45M admitted with cellulitis , RLE edema , acute on
chronic renal failure , and otitis externa.
1 ) Cellulitis: Treated with intravenous nafcillin and leg elevation. Changed to orally
diclox for d/c for more 10days.
2 ) Renal failure: Most likely prerenal- responded to IVF. Cr on discharge
was 1.9.
3 ) Otitis externa: Vosol HC 4drops four times a day given
4 ) HTN: patient was hypotensive ( 80s/50 ) 2/2 asymptomatic. IVF bolus given
and norvasc , lisinopril d/c'd. Continued labetalol with holding
parameters. BP slightly improved so lisinopril restarted.
5 ) Pulm: CPAP , albuterol , flovent
6. ) PROPH: INR 3.5- holding coumadin and restart when <3. VNA to draw INR
on 8/25 .
7. ) SKIN: Tinea pedis- lotrim lotion started twice a day
8. ) PAIN: patient was seen by Dr. Bossert ( outpt pain doctor ) re: baclofen pump.
It was decided pump should remain in place despite it not working because
patient would need surgery to remove it and he does not want surgery.
Addended Osmers , Tessa M. , PA ( YZ90 ) on 10/1/06 @ 02:30 PM
ADDITIONAL COMMENTS: 1. ) Please take dicloxacillin 500mg 4x/day for 10days for your leg
infection. Please keep your leg elevated until your infection heals.
2. ) You should no longer take norvasc until you follow up with Dr. Anestos .
She will advise you on whether you need it or not.
3. ) Do not take coumadin tonight. You will have your INR checked tomorrow
and the coumadin clinic will advise you on when to restart it.
4. ) Continue lotrim lotion twice daily between your toes for athlete's
foot until healed.
5. ) Call Dr. Anestos or come back to the hospital if you develop fever ,
pain , or increased swelling or reddness in your leg.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
*VNA*
Medication monitoring , BP checks , and INR draw on 7/28 .  INR results to be
called into LMC coumadin clinic ( 537-738-6908 ).
*primary care physician*
Norvasc was held 2/2 hypotension. Restart if needed.
TO DO/PLAN ADDENDUM 1:
*VNA*
Medication monitoring , BP checks , and INR draw on 8/25 .  INR results to be
called into LMC coumadin clinic ( 537-738-6908 ).
*primary care physician*
Norvasc was held 2/2 hypotension. Restart if needed.
Addended Osmers , Tessa M. , PA ( YZ90 ) on 10/1/06 @ 01:56 PM
No dictated summary
ENTERED BY: OSMERS , TESSA M. , PA ( YZ90 ) 10/1/06 @ 11:17 a.m.
Addended Osmers , Tessa M. , PA ( YZ90 ) on 10/1/06 @ 01:56 PM
Addended Osmers , Tessa M. , PA ( YZ90 ) on 10/1/06 @ 02:30 PM
****** END OF DISCHARGE ORDERS ******

Document id: 55

352571489 | PUO | 59749742 | | 770479 | 6/2/1999 12:00:00 a.m. | ISCHEMIC ULCER RT. LEG , LT. FEMORO-POPLITEAL GRAFT STENOSIS | Signed | DIS | Admission Date: 9/30/1999 Report Status: Signed

Discharge Date: 7/7/1999
PRINCIPAL DIAGNOSES: 1. Critical ischemia of the right foot. 2.
Stenosis of the left femoral tibial bypass graft.
HISTORY OF PRESENT ILLNESS: Mrs. Feltus is an 85-year-old woman
who is status post a left femoral peroneal bypass graft in
February of 1998 , who presented with right foot pain and
nonhealing ulcers of the right second and third metatarsal joint.
She underwent angiogram on August , 1999 which revealed right
lower extremity patent superficial femoral artery , a 90 percent
distal popliteal stenosis , and three vessel occlusion distal to the
trifurcation , and a 70 percent stenosis of the distal anterior
tibial supplying the dorsalis pedis. The left femoral peroneal had
a long segmented stricture at the level of the knee. Retrograde
filling of the left dorsalis pedis was identified. The patient
presented for surgical management.
PAST MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus. 2.
Atrial fibrillation. 3. History of deep venous thrombosis. 4.
Peripheral vascular disease. 5. Status post right hip fracture
surgery. 6. Status post suprapubic total abdominal hysterectomy.
7. Status post left superficial femoral artery to peroneal bypass
graft. 8. History of diabetic nephropathy.
MEDICATIONS: 1. Lasix 20 mg orally every day 2. Humulin 10 in the
morning 6 in the p.m. 3. Digoxin 0.125 mg every day 4. MVI one
tablet orally every day 5. Senokot two tablets orally every day 6. Vitamin C
500 every day 7. Trilisate. 8. Verapamil 60 mg orally three times a day 9.
Coumadin. 10. Lovenox 30 mg twice a day
ALLERGIES: The patient has allergies to penicillin and
Levofloxacin.
PHYSICAL EXAMINATION: The patient was a hard of hearing elderly
woman lying comfortably in bed. Her lungs were clear to
auscultation. Her heart had an irregular rhythm with no murmurs ,
rubs , or gallops. The abdomen was soft , round , non-tender ,
nondistended , bowel sounds were present. Extremities of the
extremities identified superficial ulcers between the right second
and third metatarsals. Vascular examination , on the right side the
right femoral pulse was palpable , popliteal was 2+ dopplerable ,
dorsalis pedis was 1+ dopplerable , and posterior tibial could not
be dopplered. On the left , the femoral pulse was 2+ palpable ,
popliteal was 2+ palpable , the dorsalis pedis had a biphasic
dopplerable signal , and the posterior tibial had a monophasic
dopplerable signal.
HOSPITAL COURSE: On March , 1999 , the patient was brought to
the Operating Room where she underwent a right below the knee
popliteal to anterior tibial bypass with a reversed cephalic vein
graft. She also underwent vein patch angioplasty of the left
femoral tibial artery bypass graft. Her postoperative pulse
examination identified a palpable right dorsalis pedis and a
dopplerable right posterior tibial; left dopplerable dorsalis pedis
and left dopplerable posterior tibial. The patient was ruled out
for myocardial infarction as per the recommendations of the
Cardiology team. Verapamil and digoxin were continued for
appropriate rate control. On postoperative day number one it was
noted that her right arm from which the cephalic vein graft had
been harvested was edematous , and the distal extremity was somewhat
cool. With elevation this resolved. Her digital perfusion was
excellent by clinical examination , and her neurologic function was
intact. The patient was restarted on her Coumadin on postoperative
day number two. Physical Therapy consultation was obtained and
recommended that the patient be discharged to a rehabilitation
hospital to return to her baseline functionable mobility. On
September , 1999 , the patient was discharged to Rehabilitation.
The patient will be discharged to Rehabilitation in stable
condition.
FOLLOW-UP: She will follow-up with Dr. Derham . She will also
follow-up with her cardiologist.
DISCHARGE MEDICATIONS WERE: 1. Trilisate 1 , 000 mg orally three times a day 2.
Digoxin 0.125 mg every day 3. Colace 100 mg orally twice a day 4. Laxative
of choice , one each orally every day as needed constipation. 5. Heparin
5 , 000 mg three times a day 6. NPH insulin 2.5 units in the morning and 10
units in the evening. 7. CZI insulin sliding scale. 8.
Lopressor 12.5 mg orally twice a day 9. MVI with therapeutic minerals ,
one tablet orally every day 10. Verapamil 60 mg orally three times a day
Dictated By: MOZELLA WERME , M.D. OA55
Attending: ROSALINA DERHAM , M.D. SP07  NL887/2405
Batch: 19795 Index No. L8HBOW2BJZ D: 8/12/99
T: 4/1/99

Document id: 56

946845360 | PUO | 39737797 | | 390751 | 7/30/1990 12:00:00 a.m. | Discharge Summary | Unsigned | DIS | Admission Date: 11/3/1990 Report Status: Unsigned

Discharge Date: 2/16/1990
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old man with
a long history of right sciatica ,
status post L5-L6 diskectomy in 1984 with recurrent pain times four
years. He complained of right buttock , right posterior thigh ,
calf , heel pain , left posterior thigh pain , left calf numbness and
also numbness in his right medial thigh and his left medial leg.
This has been aggrevated with sitting , bending , walking and
relieved by Valium and lying down. PAST MEDICAL HISTORY: Hiatal
hernia. Esophageal spasm producing chest pain , negative ETT.
History of duodenal ulcers and reflux. History of peripheral
vascular disease. CVA in 1985 with some residual right-sided
weakness. PAST SURGICAL HISTORY: Right femoral popliteal bypass
with multiple revisions and angioplasties. Multiple bilateral knee
surgeries secondary to osteoarthritis. Status post intestinal
obstruction. Status post cholecystectomy. MEDICATIONS: On
admission included Carafate , 1 gm orally four times a day; Pepcid , 40 mg orally every
day; Desyrel , 50 mg orally every bedtime; Davocet , orally every six; Valium , 2 mg orally
twice a day; nitropatch , 2.5 mg every 12 as tolerated. ALLERGIES:
PENICILLIN CAUSES A RASH. HABITS: The patient has a 60-pack-year
cigarette history. No ETOH. Retired mechanic.
PHYSICAL EXAMINATION: On admission revealed an obese male
lying comfortably post myelogram who
appeared older than his stated age. He was afebrile. Vital signs
revealed a blood pressure of 120/60. Heart rate of 65.
Respirations 20. HEENT exam was benign. Neck was supple ,
nontender with a moderate muscle spasm. Chest revealed diffuse
crackles , inspiratory and expiratory wheezes , increased lung
volumes. Cardiac exam revealed a regular rate and rhythm. Abdomen
was obese with a well healed midline scar without masses.
Extremities revealed no cyanosis , clubbing or edema. Right medial
scar from right ankle. Left distal leg scar. Neurological exam
revealed the patient to be a poor historian. Alert and oriented
with normal mental status. Cranial nerves II-XII intact. Motor
4/5 right lower extremity. Sensory decreased right medial thigh
and leg , left medial leg. Reflexes 2+ right brachial , 1+ left
brachial. No reflex in the lower extremities bilaterally. Straight
leg raise 30 degrees on the right and 60 degrees on the left.
HOSPITAL COURSE: The patient was admitted for myelogram and
possible surgery pending results. The patient
was admitted to the floor following myelogram. The myelogram
revealed medial deviation of the right L6 nerve root sleeve. Dr.
Chalow , based on the myelogram results , felt that the patient
needed re-exploration of his L5-L6. This operation was done on
4/23/90 .  The patient had a partial L5 laminectomy and L5-L6
diskectomy. Postoperatively , the patient had some back pain on
postoperative day number one but was doing well. He had a low
grade temperature on postoperative day number two and was unable to
void and had to be catheterized times two. By postoperative day
number two , the patient was voiding without difficulty. He had
some mild distention which was relieved after a bowel movement. The
patient was tolerating a regular diet and voiding without
difficulty and had no complaints at the time of discharge. The
patient was discharged on 2/22/90 .
DISPOSITION: MEDICATIONS: On discharge included Carafate , Pepcid ,
Desyrel , Darvocet , Valium and nitropatch. He will
return to see Dr. Chalow in approximately one week and will call
him for an appointment.
________________________________ QB705/3994
GAYLENE FANIEL , JR , M.D. IW81 D: 6/17/90
Batch: 0291 Report: Y9773I26 T: 2/28/90
Dictated By: ELENA S. BIALY , M.D. FO02

Document id: 57

210032808 | PUO | 20003943 | | 1055355 | 10/2/2006 12:00:00 a.m. | Atypical Angina | | DIS | Admission Date: 2/15/2006 Report Status:

Discharge Date: 2/15/2006
****** FINAL DISCHARGE ORDERS ******
AMODT , MALLIE 347-43-78-7
Sa Tulbirmmamehamp
Service: MED
DISCHARGE PATIENT ON: 7/6/06 AT 04:00 PM
CONTINGENT UPON HO evaluation
WILL D/C ORDER BE USED AS THE D/C SUMMARY: YES
Attending: REMLEY , EVALYN AMANDA , M.D.
CODE STATUS:
Full code
DISPOSITION: Home
DISCHARGE MEDICATIONS:
ACETYLSALICYLIC ACID 325 MG orally DAILY
Starting IN a.m. ( 10/29 )
ATENOLOL 12.5 MG orally every day before noon HOLD IF: SBP<100 or HR<50
LIPITOR ( ATORVASTATIN ) 80 MG orally DAILY
COGENTIN ( BENZTROPINE MESYLATE ) 1 MG orally every day before noon
Override Notice: Override added on 7/6/06 by
ALSPAUGH , KERRY Y. , M.D.
on order for THORAZINE orally ( ref # 294094779 )
POTENTIALLY SERIOUS INTERACTION: BENZTROPINE MESYLATE &
CHLORPROMAZINE HCL
POTENTIALLY SERIOUS INTERACTION: BENZTROPINE MESYLATE &
CHLORPROMAZINE HCL Reason for override: aware
THORAZINE ( CHLORPROMAZINE HCL ) 400 MG orally every day before noon
Alert overridden: Override added on 7/6/06 by
ALSPAUGH , KERRY Y. , M.D.
POTENTIALLY SERIOUS INTERACTION: BENZTROPINE MESYLATE &
CHLORPROMAZINE HCL
POTENTIALLY SERIOUS INTERACTION: BENZTROPINE MESYLATE &
CHLORPROMAZINE HCL Reason for override: aware
ECASA 325 MG orally DAILY
GLIPIZIDE XL 10 MG orally DAILY
SYNTHROID ( LEVOTHYROXINE SODIUM ) 100 MCG orally DAILY
LISINOPRIL 20 MG orally DAILY HOLD IF: SBP<100
METFORMIN 1 , 000 MG orally twice a day HOLD IF: NPO
TRAZODONE 50 MG orally BEDTIME as needed Insomnia
DIET: House / Low chol/low sat. fat
DIET: 2 gram Sodium
ACTIVITY: Walking as tolerated
FOLLOW UP APPOINTMENT( S ):
Dr. Tabatha Hollway 2/26/06 ,
ALLERGY: No known allergies
ADMIT DIAGNOSIS:
Atypical Angina
PRINCIPAL DISCHARGE DIAGNOSIS ;Responsible After Study for Causing Admission )
Atypical Angina
OTHER DIAGNOSIS;Conditions , Infections , Complications , affecting Treatment/Stay
Diabetes Type II HYPOTHYROID HTN schizophrenia
OPERATIONS AND PROCEDURES:
NONE
OTHER TREATMENTS/PROCEDURES ( NOT IN O.R. )
patient got 2 sets of enzymes and they were 12 hours apart and both were
negative.
BRIEF RESUME OF HOSPITAL COURSE:
70 year-old with known CAD , DM , schzioaffective disorder
p/with intermittent chest pain x12 hours. Poor historian. Reports
episode of Left sided chest pressure radiating up to shoulder/arm
while in bed lasting couple of minutes. Diaphoresis. with no
n/v/fever/cough/SOB. Had repeat episode lasting couple of seconds
since this am. No similar episodes of CP in the past. Had recent
cardiac with u and MIBI showing mod defect at the circumflex but decided
no medical trt at this point in time.
PMHx:
HTN
DM
CAD history of MI 1/13 schziophrenic/depression
Hypothyroidism ECHO: EF
65% PET 1/13 with moderate defect of the cx but did
not want any medical trt.
Meds:
Metformin 1000 twice a day Glipizide 10 orally every day , Synthroid 0.1 every day , Lisinipril 20mg
every day , ASA 81 every day , Atenolol 12.5 every day
All: NKDA
SH:No TOB/no ETOH
ETOH FH: CAD of mother and
sister
PExam: T97.7 HR64-85 BP110-165/62-78 RR20 96% on RA
FS 89 and FS 149
CVD: RRR No M/R/G
A/P: 70 year-old female with DM , HTN , CAD history of MI 1/13 , history of Right hip surgery
came in with intermittent chest pain x12 hours likley secondary to
atypical angina.
CVD: ROMI x2 with troponin and ck and CKMB nl. and cont. patient's cardiac
medications for BP control and ECG early R wave but no ST changes. physical therapy
denies any chest pain and SOB. No evidence of active cardiac ishemia.
Known defective circumflex artery but patient refused any medical intervention
at this point in time. Would like to follow up with a primary care physician as an
outpatient.
DM: cont. patient orally hypoglycemics
Normocytic anemia: ?anemia will follow up with primary care physician as an outpatient , the
work up is so far normal.
PPX: Heparin
Full Code
ADDITIONAL COMMENTS: Please Call if patient has any chest discomfort , shortness of breath , or any
increase fatigue or weakness or any other concerns.
DISCHARGE CONDITION: Stable
TO DO/PLAN:
1. Please go to your follow up appt.
2. Please come to the ER for evaluation if you have any recurrent chest
pain or any shortness of breath.
No dictated summary
ENTERED BY: LAPATRA , LETA , M.D. ( NT236 ) 7/6/06 @ 04:38 PM
****** END OF DISCHARGE ORDERS ******

Document id: 58